Why do legitimate claims for dental services get delayed, rejected or sent back for more information? According to dental claims review experts, most returns and rejections could be avoided with a combination of more complete clinical information and careful form completion.
Richard Celko, DMD, MBA, and Certified Dental Consultant (CDC) is the national dental director of utilization management for Aetna and president-elect of the American Association of Dental Consultants (AADC), the professional organization for dental benefits consulting, dental claims management and plan administration. "The most important thing," says Mr. Celko, "is to make sure the claim submitted has accurate patient and provider information."
Claims software often does not auto-populate fields correctly. Missing phone numbers, signatures or Social Security numbers will often cause a claim to be delayed or rejected. If a patient is covered under an employer's dental plan and has recently changed companies or initiated treatment under one carrier and is completing treatment under a new carrier, those changes should be noted to explain the treatment continuum.
Vicki Anderson is the president of American Dental Support, LLC, editor of Insurance Solutions Newsletter and an AADC affiliate member. She is a frequent speaker on dental coding issues and taught at the ADA Annual Session in 2005. According to Ms. Anderson, something as simple as using a patient's nickname instead of a full name ("Bob" instead of "Robert") can lead to rejection, as can a missing/incorrect birth date, address or plan/group number. The dentist's office address should be correct, too. "A surprising number of payment checks are returned to insurance companies marked 'moved, no forwarding address,'" Anderson says.
Since the dental plan does not have a patient's full medical record, medical conditions that impact treatment choices, such as the presence of braces or other orthodontia, should be noted. Progress notes must provide full explanation. Notes should be sufficiently detailed to show the need, history and treatment planned, and explain whether adjunctive procedures are or will be performed. Legibility counts, too.
"Ask yourself - if I didn't know the situation, would I understand the treatment?" says Jerome Blum, DDS, 2005 president of the AADC, a Certified Dental Consultant and a dental director at LJCCI. Complicated treatment plans require a rationale or letter of explanation, says Dr. Blum, as well as X-rays and perio charts.
Knowing the carrier's standards for frequency of treatment is important. If a medical condition or accident requires deviating from the norm, that exception must be documented in the remarks section for reviewers to consider. Dental work resulting from an accident - such as a car crash - may be covered under a patient's medical plan.
The claim form should have the proper taxpayer identification number (TIN) for the dentist. It is also important to note procedure codes accurately and to make sure that the procedure submitted is the procedure performed. "Always make sure the treatment performed matches the description as identified in the most current CDT manual," Dr. Celko advises. Obsolete CDT codes may also cause rejection, notes Vicki Anderson.
Every insurance company has different requirements, but some of the larger companies post their guidelines on the Internet. Offices that submit electronic claims through National Electronic Attachments (NEA) can obtain carrier requirements at the NEA web site (www.nea-tastattach.com).
Radiographs ("X-rays") are a common problem - both for claims submitters and claims reviewers. Submitters are often unsure when an X-ray is necessary. Reviewers report that many X-rays cannot be read because they are too dark, overexposed, handled incorrectly during processing or corrupted with chemical residue that leaves specks on the image and makes it impossible to interpret. Dr. Celko emphasizes the importance of submitting quality diagnostics.
"If the X-ray is not definitive as to the need, you need a narrative to define the need," according to Dr. Blum. Films should be oriented to note right and left, since tooth #30 looks the same as tooth #19 without markings.
Tom Limoli, Jr., the author of numerous textbooks on the administration and payment of benefit claims for over 25 years and an AADC affiliate member, is president of Limoli and Associates, sums it up this way: "Your clinical record must...tell them what you are looking for, tell them what you are looking at, tell them what you found."
Back-office processes also result in claim delay and rejection. Without complete charting to industry standards, information may not be available to fill out forms adequately. This means having proper tooth numbers, updated treatment notes and full treatment explanations. Noting when treatment was initiated is also very important.
"Remember that the consultant reviewing the claim does not have the benefit of being able to see the patient clinically," says Ms. Anderson. "A film can't show the whole three-dimensional view of the tooth," she adds. Dr. Blum estimates that many perio charts submitted do not agree with the X-rays on the same claim. Such discrepancies lead to delay or rejection.
Ms. Anderson further states that "Clinical staff often only document the services that were performed, but fail to document why the services were performed." Frequently, the chart itself does not provide the explanation. According to a web poll by Insurance Solutions Newsletter, when asked "How would you describe your dental office's chart notes?" 63% of respondents said, "There is definitely room for improvement," 22% percent characterized the notes as, "Very thorough and detailed," 8% said, "Our chart notes are woefully inadequate," 5% were not sure what needed to be documented, and 2% did not know general standards for documentation.
At a minimum, says Anderson, good chart notes should include:
* The patient's medical history
* The patient's chief complaint
* The diagnosis
* treatment plan
* Office visit dates and a description of services rendered at each visit
* A description of all radiographs taken and diagnostic models made, identified with the patient's name and the date
* The date, dosage and amount of any medication prescribed, dispensed or administered to the patient
* A record of the recommendations and referrals for treatment/consultation made to the patient, even if the patient chooses not to follow them.
Jerome Blum says that claims should only be submitted once. Claim clearinghouses often automatically resubmit claims if they have not been paid within a certain number of days. This generates duplicate submissions. If a claim appears to be delayed, he advises calling to follow up. Electronic claim filing is often a faster, more efficient choice because it minimizes handling and reduces the possibility of attachments being separated from the claim. When filing a claim for secondary insurance, Ms. Anderson notes that including the explanation of benefits (EOB) from the primary carrier is necessary.
Because carriers' requirements differ - and self-insured companies set their own rules - the ultimate responsibility for understanding coverage lies with the patient. Treatment that may be necessary and appropriate still may not be covered by contract. That is why an upfront benefits determination and a discussion of financial responsibility with the patient are essential.
"Not confirming eligibility immediately prior to treatment," is what Mr. Limoli calls the number one "deadly dental insurance mistake" (also see sidebar: Top Reasons Claims Are Rejected). He also points out that it is important to separate benefit assessment from financial arrangements. "Be certain you have written financial objectives established and agreed to prior to the initiation of treatment, as well as insurance consideration," he advises.
"Most claims are denied for contractual, rather than professional, reasons," agrees Dr. Blum. Although insurers vary widely on their protocols, some of the things that can trigger additional review and delay - include:
* Procedures that are commonly miscoded
* Procedures that are frequently abused
* Coverage under an ASO account (companies that are self-insured)
* Whether the service is temporary or definitive
* Service that appears to be inappropriate for the patient's age without explanatory documentation
* Exceeding the frequency expectation for a type of service without explanation of medical necessity
* Service that is preparatory for additional future services without explanation of the treatment plan.
The best way to speed claims processing is to understand the requirements of the insurance plans your office accepts. Take advantage of online documentation, plan-specific coding manuals and provider liaisons to find appropriate codes. Contact your provider representative if problems persist.
[Sidebar]
AADC members - practicing dental benefits consultants as well as representatives from all levels of the insurance industry - have a passion for responsible management of dental claims to meet the needs of patients, dentists and the insurance industry. As dentists and dental benefits consultants, AADC members are in a unique position to bridge the gap between insurer and provider. AADC members, many of whom are dentists, share a commitment to helping eligible patients, dentists and benefit companies get the right benefits to the right people and "do the right thing." AADC welcomes insurance professionals and non-dentists involved in the dental benefits industry as affiliate members. For more information on AADC and affiliate membership, visit www.aadc.org.
[Sidebar]
Top Reasons Claims Are Rejected
1. Using a patient's nickname instead of his/her full name
2. Substituting a dependent's Social Security number instead of the insured's number, or providing no number at all
3. Missing or incorrect patient DOB or address
4. Missing or incorrect plan/group number
5. Incorrect address or phone number for the dental practice
6. Missing or incorrect dental license number or TIN
7. Tooth number, quadrant, surface or arch not shown on claim form
8. Missing or incorrect treatment date
9. No date of prior placement for replacement of crowns, bridges, partial/ complete dentures
10. Primary EOB not included with secondary claim
11. Illegible handwriting
12. Incorrect or obsolete CDT codes
Source: Vicki Anderson, American Dental Support, LLC.
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