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Appealing Claim Denials

Each year denied and rejected claims result in revenue loss in the millions for hospitals and private practices. This results in undue stress to a provider’s revenue cycle management.

Aug 18, 2023 4.5 min read
Appealing Claim Denials

Unfortunately, both large and small dental practices, also, find it rough going due to denied claims. Despite this, a lot of practices do not appeal their denied claims because they lack time or do not know whether the claim is truly appealable. A majority of a practice’s active patient base are those with dental insurance, so not appealing  claim denials can be expensive.

Appealing denied claims isn’t exactly a cakewalk though and keeping up with the frequently changing rules and regulations can be cumbersome. Updated rules, contracts, terms, and conditions serve as catalysts for dental insurance companies to delay or reject insurance claim reimbursements.

Circumventing this situation is mandatory for a robust revenue cycle, and the first step involves understanding the reasons behind claim denials.

Here Are Some Common Reasons for Claim Denials:

Late Filing of Claims

Most insurance companies provide a timeframe within which claims need to be filed. Any claim submissions after the given timeframe leads to claim denials.

Procedures Deemed Medically Unnecessary

Some procedures may be considered medically unnecessary by the insurance company you are submitting the claims to.  This is yet another reason for claim denials.

Frequency Limitations

If a request to perform a procedure is sent after the coverage period has ended, chances are, it will not be covered by the insurance provider, leading to claim denials.

Exclusions in Insurance Plans

Some insurance plans may exclude certain procedures, leading to claim denial if the filed claim includes those procedures and the payments for these tend to go unpaid.

Plan Maximums

Each plan is covered for a certain amount per benefit period. This benefit period is usually for a year – calendar or fiscal. Insurance companies will not reimburse claims, leading to claim denials, if this annual maximum amount has been reached during that benefit period.

Incorrect CDT Codes

The Code Maintenance Committee (CMC) at the American Dental Association (ADA) makes revisions, deletions and updates to the existing CDT codes set every year. Filing claims without factoring in these updates is also a reason for denied claims.

Up-Coded and Bundled or Unbundled Services

Up-coding a service to get a higher reimbursement, unbundling of services to get additional reimbursements or bundling services to save time are also reasons for an insurance company to deny claims. Some plans may also have clauses inserted to ward off such practises.

Once the reason/s for denial has been identified, an appeal can be filed against such a denial. Submitting appeals, though possibly onerous, is not impossible.

So, Here Are Some Ways to Make Your Claims Appealing Easier:

Confirm the Reason/s for Denial

There may be multiple reasons for claim denials. Before starting the appeal process, make sure you confirm that all the reasons for the denial have been identified. Examine the insurance coverage to spot any mistakes; procedures and services that are covered will be specified in the plan. It will also include a list of any restrictions or exclusions that the insurance company has stated as not covered.

Call the Insurance Provider if Needed

When in doubt, get in touch with the insurance provider. This should ideally be done before you begin the appeals process. It gives your practice the opportunity to get additional details directly from the source and reduce chances of claim denials.

Categorize Denials

The appeals process for claims can be streamlined, and patterns in denials can be found by categorizing them. Strategies can be designed, and appeals can be done in a more detailed and accurate way, avoiding similar mistakes. Having an efficient denial management system in place can help you achieve that.

Appealing Claims on Time

Just as in the initial filing of a claim, a majority of insurance providers specify timeframes for practices to submit appeals on denied claims. Depending on the insurance provider, this timeframe can vary anywhere between 90 days to 1 year. Therefore, make sure that your appeals are submitted within this timeframe.

Follow-up on Appealed Claims

Set reminders to follow up on each claim appeal periodically. If you have contacted the insurance provider before beginning the appeals process, ask for a turnaround time to know when you can follow up for a status check. Checking on the status of an appeal can help you make sure that the claims do not slip between any cracks.

Although these tips will, undoubtedly, help you improve your appeals process, the preferred thing to do would be to avoid claim denials as much as possible.

Some Steps You Can Add to a Checklist When You Submit Your Initial Claim Are:

  • Scrutiny of the benefits
  • A thorough understanding of the terms and conditions of the insurance coverage
  • Patient education regarding potentially limited benefits
  • Verification of the service date
  • Documentation of all necessary information required to be submitted by the insurance provider
  • Use of accurate CDT codes
  • On-time claim submission

While appealing on rejected or denied claims can be time-consuming, the process is indispensable when it comes to generating revenue and bolstering the financial health of a practice.

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Aug 18, 2023 4.5 min read

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