Strategies to get Dental Insurance Claims Paid from the Trenches of our Insurance Claims Managers

Ever wonder what it takes to get a dental insurance claim paid?  Many dental offices employ one business person or office manager to do all the filing, attachments, narratives and appeals.  Larger practices will employ an Insurance Coordinator whose job is to do insurance exclusively.

At eAssist we find that often “it takes a village” to get the claim paid correctly the first time.  On our team we have ex dental insurance claims representatives,  registered and certified dental assistants and registered dental hygienists along with professional dental office managers and insurance coordinators who weigh in on the best way to get the claims paid with the supporting evidence  while working with the dental offices to create superior clinical notes with SOAP format and narratives.

Here is an example from the eAssist email “pipeline”.

(E1) Hello all, looking for some new verbiage for a narrative for a molar that has been “broken down and is cracked”.  Doctors notes give me very little to work with and they don’t practice using IOC.

(E2) Love to help but need some facts.  What is the existing restoration (age/material) and what is the new restoration or proposed restoration? The words “broken down and cracked” will not get the claim paid.  We cannot put a clinical diagnosis (supports narrative) on the claim that is not supported by the doctor’s notes and diagnosis.  

When they say “broken down” do they mean broken restoration or fractured tooth or separation of restoration from the tooth?  Is there a cusp fracture?  Which cusp? Decay undermining the cusp? Etc.  Cracked teeth are helped by intra-oral photos versus x-rays which may not support the evidence.   Sorry, you will have to get better evidence.

(E1) #14, it appears to have had an existing amalgam filling.  That’s all I got, sorry guys.  He said “broken down and is cracked” I will have to ask the doc AGAIN.  Had to send this x-ray.

(E3) It def. has an old existing amalgam restoration with recurrent decay on the DL (I am not diagnosing, but the doc can).  Once the restoration and decay are removed, the tooth was compromised.  So you could say that and that less than 35% of the tooth structure remains so crown was recommended to maintain normal function.  (Or something along those lines).

(E4) Being I was a claims examiner for many years the wording “excessive wear on tooth structure”   puts up a BIG red flag to me to deny the tooth for attrition and abrasion. When I was a claims examiner I would send a claim like that to my dental consultant for review.   I personally never like using that wording unless chart notes specifically say that. After you sent the x-ray, I saw exactly what Dr. A saw.  We don’t have DDS or DMD at the end of our names so even though we can look at an x-ray and technically diagnose what we read, we really can’t give our diagnosis. That’s why it is extremely important in what we do that we get a narrative or good chart notes from the provider. Each case is different and it’s my feeling that we should use strictly what the office states on a narrative or clinical notes for each claim so we don’t get into a sticky situation just in case the insurance does an audit. Each case is different.  

During dental examinations it is important that dental assistants and business staff listen and understand what the dentist is telling the patient and in turn this will be recorded on the insurance claim. Insurance companies pay claims based on documented details of what the tooth needs to be restored and why it needs to be restored.  Clinical notes supporting the codes on the claim are vital to payment.  The dental assistant should be recording these notes in real time in the system so that when the claim is created later it can be used as the narrative.  Intra-oral photos have been shown to be of great value in getting claims paid when radiographs do not pick up certain symptoms of the teeth and the gum tissue.  Intra-oral photos are great for supporting narratives on claims that are not supported by radiographs.

With our “village”  of claims processors we can get claims paid the first time by making sure we have what we need to support the procedures that have been completed.