Three steps for efficient insurance systems in the dental practice

By Denise Ciardello

You have a healthy number of patients coming through the door, but it seems as though the collections are not keeping up with production. The insurance companies are delaying payments on everything from crowns to fillings, which makes collecting on claims more difficult than ever. What is the secret to faster claim processing?

The secret is that the insurance companies do not want to pay on claims. Well, that’s a big DUH! The true secret is to have insurance systems put in place that will keep the collection ratio at a manageable state. This can be broken into three steps and if followed correctly, will decrease the processing time of most claims.

1. Send the claim correctly the first time. Don’t laugh! It happens all the time – sending off the claim with fingers crossed, or even insurance coordinators that try to “fight” the system by not sending X-rays or other information until it is requested. Who is that really hurting? Most electronic claims clearinghouses will warn you if an insurance company requires additional information for specific procedures. It’s advisable to heed the warnings.

Some tips for proper claim submission
• Verify that you are sending the claim to the right place. The patient telling you is not verification. Whether you use the insurance company’s website, a verification service, or pick up the phone and call, make sure that you are sending the claim to the right place. Crossing your fingers and hoping it’s right is NOT a good plan. In the words of Ronald Reagan, “Trust, but verify.”

• As a rule of thumb, send X-rays on all crowns, implants, root canals (pre and post), and scaling and root planing.

• SRP will also require a perio chart.

• Narratives need to accompany major treatment – this information should be in the clinical notes for ease of accessibility. When putting the narrative on a claim, remember that only 150 character spaces will be submitted electronically in the “Remarks for Unusual Services” box. Keep a list handy of narratives that your doctor uses frequently.

• For all crowns, document if it is an initial or replacement crown; there is a box on the claim form for this information.

Even nonclinical people can determine that by looking at the X-ray. If it is a replacement crown, what is the date of the initial placement? This is the tricky part. You are not allowed to guess or make up a date. If the initial crown was not completed in your office, you need to ask the patient how long he/she has had the crown. By explaining to the patient that their insurance will not pay on the crown unless you give a date of the initial crown, the patient is more likely to work with you. You may need to jog their memory by asking questions. (Were you married? How old was your child? Was it before 2000?)

Ideally, this information should be included in the clinical notes, so make it part of the clinical notes template.

• Finally, there are insurance companies, such as Cigna, that will only pay on a crown once the permanent crown is seated. Again, keep track of that so you can submit that information as soon as it occurs. We recommend that you document it on the crown seat appointment. Many times they will accept the seat date over the phone and will send the claim on for final processing.

2. Track outstanding claims on a weekly basis. We often see Insurance aging reports that have several pages – the most we’ve seen is 58, but have heard of reports with hundreds of pages. This is a system that needs to be worked often and with purpose. The longer the report, the more overwhelming it is to get a handle on it.

Clearinghouses will usually send a status report following the submission of claims. These reports have valuable information on them, so take a minute to look them over each day. Words like “unprocessed,” “holding,” “zero pay,” or “rejected” should get your attention. You can do the research and find out why the claim is not being processed to your satisfaction. By waiting until the explanation of benefits (EOB) comes in the mail, you are typically 30 days into the life of the claim.

The insurance websites are also a great source of information for tracking outstanding claims. Sites such as MetLife give you full details, and although the others aren’t as user-friendly, they still have valuable information.

Lastly, appeal, appeal, APPEAL! If a procedure is denied that you feel should be paid, send it back for reprocessing; this includes crown buildups that are part of the crown prep procedure. Explain why you are appealing it through a more detailed narrative. Your doctor or hygienist can help with these details.

Statistics show that 85% of all denied procedures are not appealed. Of the 15% that are appealed, 75% are reprocessed with a payment. The odds are in your favor.

3. Consider using the direct deposit.Most insurance companies will allow you to sign up for electronic transfer of funds to the practice’s bank account. This alleviates checks lost in the mail or waiting on snail mail to deliver the check. You are notified by email or fax (your choice) which claims have been processed; then the payment is inputted by getting the information from the website. The absolute best part is the speed of payment. Hygiene claims can be processed in two days and treatment claims, including crowns, will sometimes have the money in the bank within a week.

Insurance companies are not fun to deal with, but they have become the norm in most dental practices. Learning to work with them so that the money is collected quickly is imperative. Don’t let your money remain on their side of the fence any longer than it needs to be. This is the easy money. Have good, consistent insurance systems in place, and your collections will remain in line with your production.

Denise Ciardello is a respected professional in the dental consulting industry and a co-founder of Global Team Solutions, a practice management consulting firm specializing in team building and team training. She can be reached at [email protected] or (210) 862-9445.

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