Dental Billing Denials & Rejections 101

Rejection and denial are two somewhat similar but slightly different issues both meaning “no payment” for your practice’s insurance claims. Dental billing can be a struggle — between what your front office has time for, what insurance companies require from you, and what patients expect from your practice. Without knowing the secrets behind what gets a claim paid, you’re out of luck and cash when it comes time for reimbursement. Your office provides exceptional treatment daily, so getting paid should always be a priority. Let’s look at the top three reasons behind most dental billing claim rejections and denials, and how your practice can resolve, or better yet avoid, them to keep cash flow consistent.

Top 3 reasons for dental billing claim rejections

Many times claims are rejected when they reach the clearinghouse because the information does not reflect what the insurance company has on file for the patient.  

• Inaccurate patient information

Missing or inaccurate patient information is the most avoidable reason for a dental billing claim rejection. If the insurance has a different name or date of birth on file, they will kick the claim back to the office. Attention to detail when inputting the patient information into the practice management software is a quick fix. 

• Not verifying insurance benefits 

One tool in your preappointment readiness kit should be insurance verification. The majority of patients do now know the ins and outs of their coverage plan, and finding out their coverage has lapsed or doesn’t cover the treatment recommended is an unpleasant surprise. 

• Old claim forms

Many insurance companies have automated systems that check for specific boxes on the claim form. If you’re using an outdated or obsolete claim form, it will be immediately rejected. The easiest way to check if your claim form is up to date is by asking the insurance company directly. Reach out to your practice management software tech support (if available) to locate where to update the claim form in your software.

Top 3 reasons for dental billing claim denials

Imagine all of your initial claim information is submitted correctly, but a few weeks later you’re hit with a denial from the insurance company. What happened? When a claim is denied, the insurance payor has determined that the dental claim doesn’t qualify for reimbursement, and the reason will be stated on the Explanation of Benefits (EOB). Depending on the reason for the denial, the claim can be appealed. But without proper formatting or narrative templates, your team can have a difficult time appealing claims denied for the following reasons:

• Missing clinical information 

Using the SOAP structure, your subjective and objective observations of your patient’s symptoms will be written down and recorded appropriately. Without this, the subsequent treatment could be immediately denied due to lack of cause or downgraded if the insurance determines a lesser procedure was more appropriate to treat the patient’s symptoms. Never lie about what a patient is feeling but be transparent and make sure your observations are accurate for reimbursement purposes. When creating a narrative template, always be sure to follow practical SOAP notes to achieve the best results. Without effective processes, your reimbursement rate can suffer. 

• Ambiguous narratives 

Without structuring your narratives properly, your claim information becomes messy, ambiguous, and worst case, entirely inaccurate. Remember that “if you can’t show it, you don’t know it” and neither will the insurance company. Missing information such as radiographs and periodontal charting all work in your favor to show what treatment was provided and how, and ultimately get the claim paid in full.  Making sure that attachments are sent correctly is one of the most important factors in determining eligibility.

• Improper coding and medical cross codes 

Correct dental and medical coding is often the make-or-break aspect of most of your insurance claims. Having a dedicated, updated reference like Practice Booster’s Coding with Confidence manual can give you an edge over common code processes, as well as trickier ones that require a bit more knowledgeable finesse. As well as this, Code Advisor gives you the hands on tools you need for the most common questions and queries from offices just like yours.

Where can I learn about proper dental billing practices?

There is a lot of experience behind getting a dental billing claim paid, and it takes time and training to be able to spot the somewhat vague denial wording that the insurance company sends back on the EOB. Understanding the reasons behind rejections and denials is necessary when handling dental billing claims efficiently and effectively. Wondering where to start? Dental Zing is an online continuing education platform that can help you learn about the art of dental billing, all the while giving you the skills you need to succeed. As well as this, your office may consider outsourcing to a trusted partner using the nation’s leading platform for dental practice solutions:

Reject claim denials as a thing of the past

If your office is struggling between dental billing and claim submission woes, there is a better way. eAssist offers your practice the ability to achieve not only your financial goals, but restful sleep and peace of mind knowing your claims are being handled by dedicated dental billing specialists. Whether you have ballooning insurance or patient AR, you need help getting more patients on the calendar or simply verifying insurance, eAssist offers a solution. No more worrying about whether that batch of claims your office sent yesterday will be denied tomorrow. Schedule a no-obligation consultation at your convenience, and experience the ease of a no-contract partnership with the nation’s leading platform for dental billing solutions.

Ruby Pajmula

Quality Operations Director