Over the many years I've been preparing and submitting dental claims to insurance plans, I’ve had the thrill of having claims paid upon first submission, but I’ve also seen my fair share of claims rejected, denied, appealed, and ultimately paid. But there seems to be a trend in the dental office managers community, a rise in dental claims being rejected and returned for reasons that are unknown—until now.
After speaking with fellow dental office managers and other industry experts, it's fair to say that dental insurance companies have armed themselves with artificial intelligence (AI) to facilitate the claims handling process on their end. As with any new technology, there may be some quirks and kinks to fix along the way. But when it comes to the lifeblood of dental practice survival—dental insurance payments—there should be no room for error.
As dental office managers, we need to be diligent now more than ever with the process of submitting dental claims for payment. After all, dental insurance companies have been eager to deny payments from the beginning of time, so why else would they adopt this new technology other than to find more reasons to hold onto their members’ premiums and refuse to pay?
Several companies have developed AI programs labeled as “second opinion” software to assist in the diagnosis process by highlighting areas of concern on a patient's x-ray, such as caries, calculus, radiolucencies, and bone levels, to name a few. These programs have taken it one step further by sitting alongside your practice management software to help with case acceptance and boost patient retention. These AI programs were made to assist us as dental professionals, but in reality, they’re a tool being used on both ends of the spectrum and resulting in a dental claims war.
It’s now of utmost importance that dental professionals be diligent in prioritizing our timeliness of filing dental claims, submitting supportive documentation, and appealing claims that are rejected or denied. Here are my top five takeaways for being diligent in a time when automation and AI have heavily influenced our ways of submitting dental claims for payment.
5 ways for dental office managers to be diligent
Never lack supporting documentation: Dental professionals experience dental claims being denied from time to time, but the number one reason dental claims are not paid is due to lack of supporting documentation. Pre-op and post-op x-rays should be included with most dental procedures that fall under basic and major coverage. Documenting the x-ray and pointing out the problem shows the reason for treatment.
Never lack clarity: Present a clear definition of what constitutes the reason for treatment. The CDT descriptor defines the procedure codes but does not tell a story. It’s the job of the dental office manager, dentist, or team member who handles the claims process to prove the treatment was necessary. This includes providing a well-written and concise narrative that explains the reason for treatment and the expected long-term prognosis of such treatment.
Always be timely: Most dental insurance plans allow a one-year period to file or refile a dental claim to facilitate payment. In some cases, unions and self-insured dental plans may only allow 30, 60, or 90 days. Be sure to submit the claim on time and be sure a member of your team follows up on unpaid dental claims to ensure claims are sent in before the time period expires.
Always have accurate documentation: Teams need to be on board with documenting patient records. The smallest details can be of the utmost importance when submitting claims to an AI-powered system. Indicating how long a procedure took to complete, whether a patient was anesthetized, or what material was used for a specific procedure all need to be documented.
Always submit correct coding: Dental codes can change over time. Each year new dental codes are released or updated. Descriptors can change and your team must adapt to the new coding trends. It’s important that your practice management software (our office uses Archy) be up to date and current to ensure dental codes are accurate.
As we become more reliant on AI-powered tools, it’s only a matter of time before AI is handling many aspects of our daily routines. We can embrace new technology, but we must remember that we’re only as capable as our team.
Dental claims should be reviewed by a member of the team who is familiar with dental procedures and has the knowledge of what and why a procedure was performed. If we can explain why and show what, we can ensure claims are handled correctly and processed for payment.
