How to build a case for medical reimbursement claims: Part 2

2019 06 12 21 48 3004 Cpt Keyboard 400

As practices seek to find ways to help patients pay for necessary treatment, medical billing for dental procedures may offer a solution. As medical reimbursements are generally greater than the reimbursements provided by dental insurers, successful claims can aid a practice's bottom line while also helping patients.

In part 1 of this series, Christine Taxin focused on why your practice should embrace medical billing. The second part of this series addresses how to include the correct codes and what your team needs to know about claim forms.

The process of choosing the correct codes for medical billing (the International Statistical Classification of Diseases and Related Health Problems, 10th revision [ICD-10], and Current Procedural Terminology [CPT] codes) can be confusing, but often it's simply a matter of telling a clear, accurate story.

As an example, what does an insurer want when a practice files a claim for dental implants? They generally want you to answer two main questions about medical necessity:

  1. The claim has to explain why the patient lost the tooth. In general, the cause is either going to be an accident or bone loss.
  2. Then the claim needs to explain why the tooth must be replaced. Usually, the reason is either that the patient is suffering a loss of function or that tooth replacement is covered because of some other medical condition, such as cancer.

The claim form

There's a right way and a wrong way to fill the claim form out, but you might not know that just by looking at it. The key point is that insurers pay claims for procedures at a given surgical site in the order they're listed on the form.

“Medical billing is both an art and a science.”

The first procedure listed may be paid at 100%, for instance; the second at 75%; and additional procedures at 50%. Many practices make the mistake of listing the procedures in the order they occurred, which means the practice might not be optimizing reimbursement. I tell my clients to list the procedures for each surgical site in order from the most expensive to the least expensive procedure. This will help you maximize your reimbursement from the insurer.

Another way to maximize reimbursement is to include supporting documentation with a claim, including lab reports, diagnostic imaging, and more. Always include a copy of the letter of medical necessity, any medical review results, and preauthorization. Even if the insurer already has these documents somewhere in its system, submitting them with a claim can speed up processing.

I also remind my clients to double check the codes used before submitting a form. Practices also sometimes forget to read over the patient information. Typos and other errors can cause the insurer to reject your claim and delay reimbursement.

A learnable skill

Medical billing is both an art and a science. Forms need to be filled out correctly, and each insurer's rules and processes have to be followed carefully. It is an art because within those rules, a compelling picture of medical necessity must be painted.

Christine Taxin is the founder and president of Links2Success, a practice management consulting company for the dental and medical fields.

The comments and observations expressed are those of the author and do not necessarily reflect the opinions of

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