PPO Negotiation Solutions

We Level The Playing Field Between Dental Practices and Insurance Companies

dental insurance

Why Are Dental Insurance Claims Denied?

There are many reasons why dental insurance claims may be denied. Some claims tend to be more frequently denied than others. More information may be requested to decide whether the claim will be accepted or denied especially in surgical procedures.

Whatever the reason may be, when a claim is denied, it can be very frustrating for all parties involved. Your patient may not be able to get the care they need. Or, they may end up with a much higher cost for a procedure. And your practice may end up with a longer wait time to be reimbursed for your service as well. That is why it’s important to understand why claims get denied. When you do, your dental practice can provide patients with the best possible care. 

Using an Incorrect Dental Code

The American Dental Association (ADA) recognized a need in the dental community to educate dentists and dental staff on how to respond to claim rejections. One of the multiple possibilities the ADA lists as a reason for a denied claim is improper coding. Dental insurance claims need to be coded correctly when they are submitted to insurance in order for the claim to be processed successfully. That means that an incorrect code can have a big impact on whether a claim is successful or not. 

Be careful that the diagnosis, service and procedure listed match the most current code. The code may be a CDT code or an ICD-10-CM code. They may change as frequently as every year, so it can be difficult to remember each and every change. That makes this one of the top reasons for a claim denial. Prioritize learning these codes to avoid making mistakes that may be costly.

Having Incorrect Patient Information

Technology is used in so many ways that make our world an easier and more convenient place. That includes the use of technology to file and review insurance claims. Unfortunately, a claim may be denied very quickly for something as simple as misinformation. It’s difficult for a software to recognize mismatched information, even if it’s as simple as a single letter difference in a name or an incorrect number in a birth date. When entering insurance IDs, names, dates and other identifying information, make sure you’re entering information with care and double check that no corrections need to be made before you submit the final claim. 

Unverified Patient Benefits

Another potential reason for a claim denial is because the patient’s insurance doesn’t get verified before a procedure or treatment. To make things easier for your practice, it’s a good idea for a receptionist or member of your dental office staff to ask about insurance coverage before a patient even enters the office. This ensures that the patient does actually have insurance to process, that their benefits are active and that you are getting the most up-to-date information as possible, so claims don’t get denied for incorrect or out of date information. 

Even if a patient has the same insurance company, the benefits or group number could have changed. This also provides an extra service for your patient. When a procedure is checked against insurance benefits, your patients also get the comfort of knowing what they can expect. Patients may be more at ease when they are aware of what costs to them may be and whether insurance will cover a specific procedure or not. This saves your practice time and money while also bringing some comfort to your patient.

Timeliness of the Claim

There are so many possibilities for insurance coverage, it’s hard to even name them all. Even if your dental practice only accepts a select few insurance coverages, that doesn’t mean it’s any easier to remember each company’s deadline for filing a claim. Claims that are filed outside of an insurance company’s specified time frame will be denied. Some insurance companies may have a time limit of a year while others may allow 180 days. It may even be a time span as short as 90 days. To avoid a claim being denied and to ensure that you or your dental staff have the easiest job possible, make your best effort to file a claim as soon as a service or treatment has been completed. 

If your dental practice is struggling with getting dental insurance claims approved by insurance companies, review these items. You may find that some of these simple solutions like double checking for human error with patient information, educating yourself on dental codes, verifying insurance benefits and entering claims in a timely manner may save you and your office staff from extra work.

If you’re looking to make your dental practice the most effective it can be, contact PPO Negotiation Solutions for more assistance with money and time-saving claim filing expertise. 

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Tips for Negotiating Dental Credentialing Contracts

As a dental practice, you are likely investing ample time and energy in your patients, to ensure the best patient outcomes. But are you also investing enough time and energy to ensure you are getting the most opportunities for growth and profit? Why is credentialing important and how can it help my dental practice? Since organizational growth and development equals positive patient outcomes, let us look at some successful tips to negotiate dental insurance credentialing contracts.

The Importance of Credentialing

First, it is important to understand why credentialing is important. In short, credentialing is the process of verifying a dentist’s background for an insurance company. Patients are now more likely to choose services from dental providers that are in-network with their insurance company due to costs. It is very important to be credentialed with various insurance plans. By credentialing with a wide number of popular plans, your client base can be greatly increased. Different insurance companies require different applications and processes to become credentialed with their organization. Weighing the pros and cons with each insurance provider is essential before entering a contract.

Assess Opportunities

Assess your opportunities for growth with different payment options and insurance companies. Explore in-network vs out-of-network opportunities. If your dental practice is in a populated area, explore different employers in your local community. Are there large organizations that carry a particular plan? If you were to enroll in their plan, is there potential for a large gain in clientele? Becoming in-network with that plan may be a good financial move.

Consider other competing dental practices in the area, as well. Enrolling in a large organization’s plan could increase competition between you and other practices. Contact the large organization’s HR department for marketing and insurance. But be sure to understand all the details of the plan first to avoid any unneeded stress on your practice. Evaluate the potential workload and ensure your staff is equipped to handle the increase in workload.

Here’s an example scenario for seizing an opportunity for growth. There is a large healthcare chain in your local area, and it owns several local hospitals, walk-in clinics, and offices. You contact the HR department of the chain and find that they use a particular insurance plan for the entire healthcare organization. Enrolling in this plan would make you an in-network dental provider to all employees of this chain, increasing your potential client gain.

Reimbursement Opportunities

Using a skilled negotiator to negotiate fees and credential scheduling can be a useful tactic. Stay up to date on the latest information about popular insurance plans. Even though some insurance companies advertise that they are non-negotiable, ask to negotiate. Some plans will only offer negotiation if you are a specialist, so be mindful, and consider hiring a negotiator.

Be aware of third-party companies. They may have better scheduling, but there could be hidden costs. If needed, consider outsourcing negotiations until your staff is up to date. The American Dental Association posted an article on their website encouraging dental companies to negotiate with insurance companies for higher reimbursement rates. The article stated that companies used to negotiate with insurances were “on the rise,” and a doctor in the article mentioned that it allowed her more time to focus on her patients. Carefully consider which negotiation specialist is right for you and your company.

Read the Fine Print and Renegotiate

It is safe to say that if it is not mentioned in the contract, it is not an offered service. Do not make assumptions. If you feel like there is something missing from the contract, investigate whether or not it is an offered service and request clarification in the contract. Be aware of some insurance companies with contracts that are more difficult to navigate and weigh the pros and cons of entering a contract.

For example, Medicaid can be difficult to navigate and typically requires a lengthy credentialing process. However, if a large population in your area carries Medicaid, it may be beneficial for your dental practice to offer Medicaid as an in-network service. If you are looking to re-negotiate with an insurance plan, make sure you are updated on current plans in your area and what your fees should be. Determine the leverage you can use by knowing what services you can offer in your area and the patient demand of the services. Contact the plan carrier and request a custom fee schedule based on your selected billing codes.

Company Contracts

Consider contracts with companies to do negotiations for you. How can companies like Strategic Practice Solutions be helpful? They can increase insurance reimbursements, create new patient opportunities and decrease negative impacts on patients. Their goal is to increase your revenue and increase your dental practice’s knowledge of insurance negotiations. They work full-time on your dental contract negotiations, so you can be free to better serve your patients. Save yourself the time and money and contact them today.

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What is Credentialing in Dental Care?

Dental credentialing is a process in which a dentist enters a contract with an insurance provider in order to offer those dental insurance benefits to clients. The benefit to the dentist is access to a larger client base and increased business opportunities. However, it can be a rigorous process to get credentialed by an insurance company. So, why would a dentist choose to be credentialed? If you choose to be credentialed, what is the process for doing so? This article will discuss the ins and outs of dental credentialing to get you started in the right direction for your dental practice.

Benefits of Credentialing

In order to enter a contract, dentists must provide proof of a dental degree and license, malpractice insurance, and law compliance. It is important to read through a contract before signing it. The contract gives details about the insurance plan and will also list what a dentist can and cannot charge a patient for specific dental services.

Sometimes, an insurance company will state that some services are not billable. For example, if a patient’s temporary crown becomes loose and needs to be replaced, insurance may state in its terms that this is not a billable service. But for self-pay or out-of-network, a dentist might bill a charge to replace a temporary crown. These may seem like cons to credentialing. However, many patients rely on dental insurance to afford dental care. Often, patients will refuse dental care based on their out-of-pocket costs.

Dentists within the same dental practice can choose to either be “in-network” or “out-of-network” with the same insurance provider. Each dentist will be credentialed individually if they choose to be in-network. Take time to explore which insurance providers are common in your area, and which ones will most affect your client base before entering contracts.

How to Get Credentialed

Once you have decided to move forward and join with an insurance company, there are a few steps that you need to take. First, you will need to do a full application before reaching out to dental insurance companies. This can be made easier by using the credentialing tool on the American Dental Association’s website. It will give you a list of documents that you will need. These include your NPI number, dental license, proof of malpractice insurance, DEA certificate, specialized degrees or certificates and professional references.

Once your application is submitted, you can reach out to dental companies and make inquiries. Begin by going to the company’s website and looking for an option to join their network. After submitting an inquiry, the company will send you a contract. Make sure you receive a fee schedule, and thoroughly review it. Negotiate to your approval. Sign only when you are satisfied with the results.

Tips for a Smoother Application Process

Now that you know the importance of credentialing and the basics of how to get started, let us discuss how to get the process done quickly and efficiently so that you can get to taking care of your patients.

First, make sure that you enter a response for each application question. Even if it does not apply to you, enter “N/A” rather than leaving it blank.

Next, make sure your malpractice insurance, all submitted forms, and signatures are updated. The credentialing process can take several months, and you do not want it to take longer due to a clerical error that was preventable.

Once you submit the application, confirm it was received. Routine follow-ups via email with insurance companies are important. Keep a log of who you contacted, when and what the details of the response. Routine follow-up will ensure you get the responses in the timeliest manner. It can be a painful process, but will be worth it for both your patients and your practice.

Beware of Medicaid

Depending on the size of your practice, there are some insurances you may want to look out for when it comes to choosing with whom you want to enter a contact. Medicaid insurances require a few more steps and a bit more effort to maintain and therefore may be recommended for larger practices. For one, it is two different application processes – one process with the state, and another with a managed care company. You will need a state Medicaid provider number. And typically, the credentialing process takes longer than other insurances. It may take more time in consistent follow-up emails and phone calls.

Getting credentialed for your dental practice is time-consuming and leaves less time to focus on your patients. There is another option. Consider outsourcing and hiring a third-party company to take over this process for you. Companies like Strategic Practice Solutions can provide company training for office managers to help dentists keep up with credentialing or manage it all for you. Contact them today for your dental practice needs.

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Tips for Dental Insurance Credentialing

As a dental practice, you are likely investing ample time and energy in your patients, to ensure the best patient outcomes. But are you also investing enough time and energy to ensure you are getting the most opportunities for growth and profit? Since organizational growth and development equals positive patient outcomes, let us look at some successful tips for dental insurance credentialing.

Importance of Credentialing

First, it is important to understand why credentialing is important. In short, credentialing is the process of verifying a dentist’s background for an insurance company. Patients are now more likely to choose to go to providers that are in-network with their insurance due to costs. It is very important to be credentialed with various insurance plans. By credentialing with a various number of popular plans, client base can be greatly increased.

Assess Opportunities

Assess your opportunities for growth. If your dental practice is in a populated area, explore different employers in your local community. Are there large organizations that carry a particular plan? If you were to enroll in their plan, is there potential for a large gain in clientele? Consider other competing dental practices in the area, as well.

Enrolling in a large organization’s plan could increase competition between you and other practices. Contact the large organization’s HR department for marketing. But be sure to understand all the details of the plan first to avoid any unneeded stress on your practice. Evaluate the potential workload and ensure your staff is equipped to handle the increase in workload.

An example scenario for seizing an opportunity for growth would be a large healthcare chain in your local area that owns several local hospitals, walk-in clinics and offices. You contact the HR department of the chain and find that they use a particular insurance plan for the entire healthcare chain. Enrolling in this plan would make you an in-network provider to all employees of this chain, increasing your potential client gain.

Consider Current Clients

Consider your current clients. Are the majority in-network or out-of-network with your current plans? If you were to make a major change, how would that affect your revenue? There may be the possibility of losing current clients if you were to no longer accept their insurance plans at your business. On the other side, could changing to this plan be beneficial to the majority of your current patients? It may allow patients to receive more dental care or procedures they otherwise could not afford. Your current patients’ satisfaction is equally as important as gaining more clients.

To place this point in perspective, say your clinic has approximately 50% of clients with one plan and 50% with another major plan. If your clinic were to go out-of-network with one of the major plans, you could potentially lose 50% of your patients if they were to decide to switch to a different office that was in-network. If a large amount of your patients are out-of-network with a plan and could be in-network, you could make a larger profit and the patient may have more benefits, as well.

Reimbursement Opportunities-Negotiation

Using a skilled negotiator to negotiate fees and credential scheduling can be a useful tactic. Stay up to date on the latest information about popular insurance plans. Even though some insurance companies advertise that they are non-negotiable, ask to negotiate! Some plans will only offer negotiation if you are a specialist, so be mindful and consider hiring a negotiator. Be aware of third-party companies. They may have better scheduling, but there could be hidden costs.

If needed, consider outsourcing negotiations until your staff is up to date. The American Dental Association posted an article on their website, encouraging dental companies to negotiate with insurance companies. The article stated that companies used to negotiate with insurances were “on the rise” and a doctor in the article mentioned that it allowed her more time to focus on her patients. Carefully consider which negotiation specialist is right for you and your company.

Dig Deeper

More profit for your business could be obtained by ensuring that you are not underutilizing dental codes. Are you aware of all the dental plans in which you are enrolled? Ensure your staff is adequately trained to code reimbursement forms effectively. Optimizing your insurance plan’s coding tools effectively is essential to ensure increased revenue and to ensure the best patient outcomes. Another tactic is to explore the cash prices being charged by other dentists in your area. You want to be sure you are charging enough for your services.

Company Contracts

Consider contracts with companies to do negotiations for you. How can companies like PPO Negotiation Solutions be helpful? They can increase insurance reimbursements, create new patient opportunities and decrease negative impacts on patients. The Mission of PPO Negotiation Solutions is to “enrich dental practices, not only through increasing their revenue, but also their understanding, while streamlining processes for optimal day to day well-being.”

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