5 steps to appeal denied claims

2019 09 24 21 39 2685 Anderson James 400

When you notice your total accounts receivable is on the rise and is aging to 60 days or more, who do you turn to for answers to questions? Most dentists would say their office manager handles all of the billing issues. But when the dentist discovers that most of the money in the accounts receivable is unpaid insurance estimates, the next question is inevitably some form of "Why aren't these claims paid?"

Appeals to denied claims and narratives to support claims are usually about clinical facts, not administrative errors. When a letter is received from the insurance company stating the submitted claim evidence doesn't support the need for treatment, or they are requesting more information, your insurance person goes back to the patient's chart for the data. Much of the time it isn't complete in that it doesn't have enough detail. The scenario leads to a backlog of claims needing information.

Routinely denied

James Anderson, DMD.James Anderson, DMD.

In our experience, the procedures routinely denied for coverage include the following:

  • Scaling and root planing
  • Periodontal maintenance
  • Crown/bridge and implant procedures
  • Periodontal surgery
  • Extractions

Denials often occur because the information submitted doesn't meet the criteria for claim payment as set forth by the contract. As limitations, exclusions, and frequencies vary from plan to plan, it is vital to find out what is covered and not covered before performing any procedures.

Many a time there have been requests from insurance billers asking for the "magic bullet" narrative that has a proven record of getting similar claims paid. Insurance companies will red flag cookie-cutter narratives and deny claims.

What is the difference between an appeal and a narrative?

Clients often ask us to explain the difference between an appeal and a narrative.

  • An appeal is a written request by the healthcare provider (dentist), the patient, or both to take a second look or review of a claim that was denied benefits or given an alternate benefit of a lesser amount.
  • A narrative is a brief, written statement by the provider describing the evidence or reason the procedure was performed to justify medical or dental necessity.

5 easy steps to avoid denials

1. Verify information and fill out the claim correctly

“Appeals to denied claims and narratives to support claims are usually about clinical facts, not administrative errors.”

This can be done by providing accurate patient information, subscriber ID, gender, date of birth of the patient, relationship to the subscriber, group number, employer, and insurance verification. Your practice should also verify the coverage and the patient eligibility by obtaining a breakdown of benefits from the insurance company.

Also determine that your claim is going to the correct clearinghouse or portal for submission.

The most common mistakes seen on claims are the absence of information and attachments. Often unmarked radiographs are separated from the insurance form and get lost. The same thing applies to the intraoral photo(s). It is always recommended to use electronic attachments when sending radiographs, photos, periodontal charting, and descriptions.

2.Check the codes for accuracy

The ADA owns the codes, and many are revised, deleted, or added each year. Using deleted codes or the wrong codes will deny a claim and will cause a costly refiling. Updating your dental software when a new version comes out will update to the latest code set; purchase the latest CDT codes yearly from the ADA.

3. Briefly state the narrative

The carrier is looking for the language in the narrative that fits the contract criteria to pay the claim. Use subjective, objective, assessment, and plan (SOAP) notes or state the chief complaint, diagnosis, and treatment planned. What is not evident in an x-ray but is seen visually or by other means must be included in the narrative. Each narrative should be customized to the individual patient's clinical findings.

A narrative should briefly state the condition that the patient presented at the time of clinical examination. For instance, "Patient presents with periodontal disease, class (0 to V) including BOP, exudate, mobility, and 4-6 mm periodontal probing depths on the following teeth #."

If the dentist notes evidence of periodontal disease in the first part of the evaluation, use the evaluation code D0180 and include the documentation.

4. Communicate your efforts to the patient

Sometimes the patient or guarantor will have to be asked to participate in the appeal process. When you are down to your last appeal, a statement or letter from the patient regarding their satisfaction with the treatment and demand for their benefits has won many an appeal.

5. Follow up on all claims systematically

Follow them until they are paid. Make outbound calls to the insurance company. You want to get confirmation that the claim is in the process to be decided and the expected date of the outcome.

Be prepared to speak to a supervisor if payment is not received.

The consultant reviewing your claim needs to know the specific diagnosis or condition for which the treatment is being performed. In the case of a crown, the specific details that need to be addressed in a narrative include the following:

Crown: Tooth #___ Existing restoration is? ____Filling ____Surfaces ____Onlay ____Crown ____Other

Age of existing is? _______ Remaining tooth structure _______

Clinical reason to replace existing restoration is? Decay____ Surfaces____ Fracture____ Pain/cracked tooth____ Decay undermining__________

Missing restoration? ______ Undermined cusps #_____ Perio/endo prognosis/status________________

Initial placement of this crown? Yes_____ No_____ Date of initial placement_________

Getting claims paid the first time is the goal and giving the insurance companies what they need from the start is the answer.

James Anderson, DMD, is a practicing dentist in Syracuse, UT, and is the CEO/founder of eAssist Dental Solutions. He can be reached via email.

The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.