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Here is how I would suggest doing your verification: As soon as you receive a new patient’s insurance information, verify their benefits. This can be done by phone, or online. Each office has their own specifications as to what they are looking to verify. Minimally, you want to make sure you know the basic coverage and that their insurance will pay if they come to your office. I would suggest that you have a benefit breakdown form to follow along with and fill in all the information you need as you go. There is a template available in the Resources section of our site that you can use or adapt to work for your office.

I would not wait until the day of the appointment to do this if you can avoid it. Try to get the benefits verified at least 48 hours in advance so that when you make the confirmation calls you are confident that their insurance will work in your office. If there were any issues that arose during verification, you will then be able to discuss them with the patient during your call and prior to their treatment.

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We don’t do too many predeterminations because it is our philosophy that no matter if the insurance says they will pay for a procedure or not, does not determine if the patient needs it. That being said, we do have some that go out. For example, if someone is considering a procedure that is more of an optional type procedure or something that they can wait for a decision on, such as implant.

We send predeterminations on the same day or the morning after the consultation. Typically our process is that to stage the predetermination in Eaglesoft, like the claims do when patients get walked out. That night all the notes are put in for the day which will help us with adding narrative for the procedures that need it and the predeterminations, to help get them approved. The next morning the appropriate information is added to the claims or predeterminations and they are sent to the insurance companies.

We then pull predeterminations on a report much like outstanding claims and call on them as we call on open claims. Once the predetermination is received by the office, the treatment coordinator then calls the patient with the information and attempts to get them scheduled.

On one other side note, we started working with a company called eAssist that handles all of our insurance entering and processing. I wanted to share this because their entire focus is handling all of our insurance issues in the office. There are two reasons that I love it….. 1) it frees up my staff to focus on customer service and patient care and keeps them off the phones for hours with the insurance companies and 2) they are paid a percentage on insurance collections per month, so they are motivated to keep the claims and payments current and do their best to get the maximum payment possible for our office and patients. I used to have to pay one full time employee to do all of that and to me that seems like such a waste of talent for a great employee who could be helping in the office and with patient care.

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We certainly understand the frustrations with insurance companies and their propensity to deny claims. We must always remember the insurance belongs to the patient so we need to start by always letting the patient know we are doing the best for their dental health by providing the recommended treatment. We will be happy to file their insurance claim for them but the insurance companies can and are in the business to deny claims whenever they can so if they have an issue with what the insurance company denies, etc. they should take it to their HR department for review. If the corporation/company providing the insurance to their employees complains enough to the insurance companies or threatens to leave that is the only time the insurance companies seem to sit up and take notice.

The 3 D’s with insurance companies are Delay, Decline & Deny. The most common mistake made when filing an insurance claim is the absence of information and attachments. Providing the wrong information can cause headaches, but also not providing the right amount of information can cause the same delay or denial. Also, providing the same, unvaried, or routine narrative for claims that are similar can also raise red flags to the insurance examiner so vary them each time they are sent especially when sending to the insurance carrier you are having issues with.

The narrative should always contain the periodontal condition that the patient presented with at their exam as well as the amount of time it has been since they were last seen in a dental office. Most carriers want also require the American Academy of Periodontology Case Type explained on the claim form as well. Example: “Patient stated they have not been seen in a dental office or had any type of periodontal care since (Date/or approximate amount of time.) Patient presented with Case Type III-Moderate Periodontitis including generalized 4-6 mm periodontal probing depths, Bleeding on Probing, Mobility (state specific teeth if not generalized) exudate, (if present).” Also mention the amount of deposits present and refer to intraoral photos for evidence of this, furcation involvement, missing teeth and recession. Always include a current FMX w/ BWX or preferably VBX if available and periodontal charting showing comparisons if available. Any other detail from the hygienist’s or doctor’s clinical notes and intraoral photos if available.

Also, be sure you are up to date with the new code that has been introduced and available for use as of January 2017. Here is a link to the ADA site with more information.

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