I don’t know about other areas of the country, but in my neck of the woods I’m hearing from offices that insurance companies are denying their claims in record numbers. Even in my own office, where we typically have only $1,500 to $3,000 in outstanding claims over 30 days, that number has climbed to more than $5,000. And there doesn’t seem to be any pattern to follow, where we could nip it in the bud with one quick fix. What I can say is that the issues I’m seeing are not being picked up with the eClaims triggers, so we as office managers and financial coordinators must troubleshoot the problems and fix them on our own. Let’s take a look at where some of the problems arise, and I will give you some suggestions on how to create a better insurance claim.
One problem I’m seeing is an increase in how often buildups are denied. In the past some doctors would place a buildup and not charge a patient for it. I think they felt they were giving patients good service by saving them some money. However, now with insurance companies reducing our provider reimbursements significantly, it makes me wonder if the doctors are now not giving away as much treatment and finally billing the buildup out to the insurance company to make up for this difference. In any case, a buildup requires a clinical narrative and in some cases an X-ray to justify the procedure. This narrative goes in the Remarks for Unusual Services box on the claim form. A good narrative should include description of the existing restoration, the current condition of that existing restoration, and the current disease of the tooth. For example — “Existing crown 10+ yrs old, ill fitting, recurrent decay, insufficient tooth structure to support new crown.”
Another problem I have seen lately is claims being denied because the address does not match in the Billing Provider box and the Treating Doctor box. If you are using two different providers in these two sections, make sure the addresses match. Go to the Provider setup on the office manager to check.
There are also some specialty boxes within the claim that need to be filled out in some situations. From the ledger double click on the insurance claim, double click on the claim information box, and this will open a new window where you can enter some pertinent information such as orthodontic banding dates, removable prosthetic information, pre-authorization numbers, and more. If we can fill out the claim completely the first time, then we can hopefully avoid the frustration of a denied claim in the future.