Troubleshooting Denied Claims. Could the answer be in the EOB narrative?
I frequently get questions and complaints regarding denied claims. My first response is to ask additional questions. Typically, I ask ”What does the narrative say for the denial; why was the claim denied?” My second usually is “Who is the carrier?”
There are many reasons why claims get denied but it’s either due to lack of medical necessity or contractual limitations.
Let’s talk about medical necessity first.
If your claim submission lacked the appropriate documentation to show medical necessity, send a copy of the denied EOB along with any additional supporting documentation (narrative, drawing, photograph, chart notes etc.) to explain what could not be seen (or may not have been obvious) with the initial claim.
Put yourself in the dental consultant (reviewer’s) seat for a moment. They don’t get the benefit of examining the patient. The only information they have is what you provided. To issue a benefit, strict guidelines and criteria need to be met. Sometimes the insurance carriers are using their money to pay the claims and sometimes they are authorized as a “third party” to just administer the plan. That means they are not using their money to pay the claim; they are using the employer’s money. Just because you made a diagnosis, provided a service, and it’s a covered benefit under the plan doesn’t mean the claim will be approved.
Obviously, some things cannot be viewed on a radiograph; for example, a lesion on the buccal or lingual surface. If that’s the case, make sure to include a written narrative about what you have observed clinically and oh, by the way – your patient record notes should reflect the same. Think proactively. If someone were to question why you provided a restoration, what documentation do you have to show why? “Our office doesn’t do unnecessary restorations” won’t cut it if you are the lucky recipient of an audit. Do you have films that clearly show necessity? If it can’t be seen radiographically, did you make mention in the patient record? Did you take a photograph? Did you chart active caries? Poor oral hygiene? High caries risk? Xerostomia? Anything? Your chart notes should reflect what you did, but just as important WHY. That is the basis of medical necessity. What’s the diagnosis?
If the clinical information you sent doesn’t check the “required boxes”, the consultant will have no other choice than to deny benefits. Sometimes they will ask for the additional information. If that’s the case, re-send everything and the additional information. I know you already sent it 50 times……got it 😊 but….(there is always a but)….. the consultant may not have the ability to retrieve the information you sent with the original claim and likely upon re-submission, the claim and attachments will go to a completely different reviewer who will then be looking at it for the first time.
If you receive a denial based on a “questionable prognosis” and you disagree, ask for reconsideration. Re-submit the claim and make sure you address the issue of “prognosis”. Include any clinical supporting documentation (including any specialists consultation notes) to demonstrate why the patient is an appropriate candidate for the service you have provided. What s obvious to you may not be obvious to the reviewer; make their job easier and provide information that tells them the entire story.
Now let’s talk about contractual language.
If the denial is due to contract language – typically that means that the patient’s plan contractually excludes the denied service. You could stand on your head, spin around and resubmit a100 times but the decision will not be overturned because the patient’s plan does not allow coverage for that service under the terms of the contract.
What does that mean? Well, if you don’t pay for collision on your car insurance and you total your car – you won’t see a check from your auto insurance carrier! It doesn’t mean you don’t need a new car…it just means you are on the hook for it. So in terms of dentistry, the denial doesn’t indicate the patient doesn’t require the service you recommended, it means they have no coverage for it…so they are on the hook for it. I know you don’t like to hear this, but CHARGE YOUR PATIENT!
If you do find yourself in this situation – you can refer your patient to the Employee Benefits Manager or Human Resource Manager if they receive benefits through their employer. If the plan is SELF FUNDED, meaning the employer is paying the claims approved and the Insurance Carrier is just the administrator of the plan….the plan holder (employer) may be able to override the original determination and direct the insurance carrier to pay the claim. Sometimes the old saying “the squeaky wheel gets the oil” is true.
If you have exhausted all your avenues for appeal and still feel the consultant is reaching inappropriate conclusions about the quality or appropriateness of treatment and/or denying a claim, you can reach out to us at NJDA or the ADA’s Third Party Payer Concierge.