Your Patient's Claim Was Denied... Now What?

Dealing with denied insurance claims is a frustrating, yet unfortunately common, part of running a dental practice. It impacts your revenue cycle and can lead to awkward conversations with patients. But fear not! A denial isn't always the final word. With a systematic approach, you can often overturn denials and get the reimbursement you deserve.

So, what should you do when a patient's claim is denied? Here's a step-by-step guide:

Understand the Reason for the Denial

The first and most crucial step is to figure out why the claim was denied. The Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) from the carrier should provide a denial code and explanation. Common reasons include:

• Incorrect or Missing Information: A simple typo in the patient's ID, incorrect birthdate, or missing procedure code can trigger a denial.

• Non-Covered Service: The patient's plan might not cover the specific procedure performed.

• Frequency Limitations: Most insurance plans have coverage limits for particular procedures (e.g., cleanings every six months or bitewings every 12 months).

• Pre-Authorization Required: Certain procedures may require pre-authorization from the insurance company before they are performed. These are typically for major category procedures.

• Bundled Services: The insurance company might consider the procedure part of another service already billed.

• Eligibility Issues: The patient's insurance coverage might have lapsed or be inactive.

• Duplicate Claim: A claim for the same service might have already been submitted.

Gather Documentation

Once you understand the reason for the denial, gather all relevant documentation. This might include:

• Patient's Chart: Review the patient's clinical notes, treatment plan, and any supporting documentation like x-rays or intraoral photos.

• Original Claim Form: Have a copy of the initially submitted claim.

• EOB/Remittance Advice: Keep the denial notice from the insurance company.

• Insurance Policy Information: If possible, access the patient's insurance policy details to confirm coverage.

• Pre-Authorization Documentation (if applicable): If the procedure required pre-authorization, have that documentation ready.

Determine Your Next Steps

Based on the reason for the denial, decide on the appropriate course of action.

• Resubmit the Claim: If the denial was due to incorrect information, correct the error and resubmit the claim promptly. Make sure to highlight the corrected information. Use the original claim document number to avoid a duplicate flag.

• Appeal the Denial: If you believe the denial was unjustified (e.g., non-covered service that you believe is covered, or a denial based on medical necessity), file an appeal with the insurance company. Follow their specific appeal process and deadlines. A well-crafted appeal letter should include a clear explanation of why you disagree with the denial, supporting documentation: clinical notes, radiographs, intra-oral photos, patient history, letter of necessity (narrative of why treatment was necessary), relevant coding information, and the patient's contact information. You can even use artificial intelligence (AI) to help with your letter.

• Contact the Insurance Company: Sometimes, a quick phone call to the insurance company can clarify the denial reason and expedite the resubmission or appeal process.

• Adjust the Patient's Balance: If the denial is valid (e.g., unappealable non-covered service), you'll need to discuss the financial responsibility with the patient. Be transparent and empathetic, and offer payment plan options if necessary.

Prevent Future Denials

While some denials are unavoidable, you can take steps to minimize them:

• Verify Insurance Information: Always verify patient insurance information before providing treatment.

• Accurate Coding: Ensure accurate and detailed coding of procedures.

• Stay Updated on Insurance Policies: Keep up-to-date with changes in insurance policies and regulations. Regular benefit verification can help with this.

• Pre-Authorization: Obtain pre-authorization for procedures that require it.

• Clear Communication: Communicate clearly with patients about their insurance coverage and potential out-of-pocket expenses.

WATCH: The Key to Clean Claims

Dental operational efficiency expert, Cassie Tallon, understands that dealing with insurance claims is like playing an endless game of ping-pong, bouncing back and forth trying to get everything sorted. She shares how practices can get clean claims the first time so they can spend more time with their patients and less time on the phone with insurance companies.

How Curve Dental^® Can Help

Streamlined Practice Management for Fewer Denials

Curve Dental’s award-winning, cloud-based platform, Curve SuperHero™, provides robust practice management features that help you create, organize, and maintain accurate patient records—all in one place. This level of organization is crucial when it comes to managing insurance claims and minimizing denials. By keeping your treatment notes, insurance details, and patient history accessible in a single, centralized system, you can quickly identify the reason for a denial, gather supporting documents, and either correct and resubmit or file an effective appeal.

Real-Time Eligibility Checks

One of the most common causes of denials is eligibility issues. Curve SuperHero offers real-time eligibility verification, enabling you to confirm a patient’s coverage and benefits before starting treatment. This feature helps you:

• Identify gaps in coverage early.

• Reduce claim rejections due to inactive or changed policies.

• Set clear financial expectations with patients from the start.

Quick & Accurate eClaims

Curve automates the submission of electronic claims and attachments, reducing the chance of manual entry errors. With built-in eClaim submission:

• Claims are automatically checked for missing or invalid information before sending, catching errors in advance.

• You can send claims to insurance payers with just a few clicks, accelerating turnaround times.

• You receive faster responses and can act on denials or requests for more information more quickly.

Automated ERA Processing

Manually posting payments from insurance Explanation of Benefits (EOBs) can be tedious and prone to error. Curve supports Electronic Remittance Advice (ERA):

• Payments are automatically posted to the correct patient account.

• The system flags any discrepancies for quick review and resolution.

• Your team saves valuable time by reducing manual data entry.

Enhanced Patient Communication

Transparent communication about treatment costs and insurance coverage is essential to maintaining trust with your patients. Curve helps you:

• Generate accurate patient estimates based on verified insurance benefits.

• Provide clear treatment plans that detail potential out-of-pocket expenses.

• Automate appointment reminders and follow-ups to keep patients engaged.

Detailed Reporting & Analytics

Curve offers robust reporting features to help you analyze and optimize your revenue cycle:

• Track key metrics like outstanding claims, average reimbursement times, and claim acceptance rates.

• Identify trends in denials, allowing you to focus on coding accuracy, plan coverage, or other common pitfalls.

• Create custom reports to refine your practice’s financial strategies and reduce future denials.

Take Control of Claim Denials with Curve SuperHero™

Denied claims don’t have to slow your practice down. With the right approach and the right tools, you can efficiently resolve denials, maximize reimbursements, and prevent future issues. Curve SuperHero empowers your team with real-time eligibility verification, automated ERA processing, and seamless claims management—helping you get paid faster and reduce administrative headaches.

Ready to streamline your claims process? Schedule a demo today and see how Curve SuperHero can transform your insurance workflows!