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How to Appeal a Dental Insurance Claim Denial

Denied dental claims can cause stress for not only you and your practice, but your patients as well. Unfortunately, this is a common problem for practices large and small. Reimbursement from insurance providers is vital to the survival of your practice—something insurers may use as leverage.

You already work long hours running your practice and helping your patients. When you are facing unfair claim denials on top of everything else, you deserve help challenging those denials.

By hiring an experienced medical practice lawyer, you can fight back against unfair dental claim denials without taking attention away from running your practice. At Bryant Legal Group, we help dentists and other medical professionals negotiate with health insurance providers, file appeals, arbitrate and litigate disputes with insurance companies in order to get the payment they deserve for their services.

In this article, we will highlight common reasons why insurance companies deny insurance claims, what to consider when filing an appeal, and how dental practices can avoid claim denials in the future.

Common Reasons Your Dental Insurance Company Might Deny Dental Claims

When it comes to insurance claims, there are certain rules laid out in your contract that can cause headaches down the road. Insurance policies and insurer provider manuals often contain a series of clauses that protect the insurer from having to pay out certain claims.

Whether or not these denials are always valid, however, is another story.

To best understand when and when not to file appeals, you must first know the reasons why claims are typically denied. Once you can identify the opportunities to appeal, you will be able to protect your practice from wrongful denials and help your patients get the help they need.

The five most common reasons for an insurance claim being denied are:

  1. Frequency limitations: A procedure is requested to be done outside the time frame of coverage. Insurance will not cover these procedures, no matter the reason.
  2. Plan maximums: Insurance companies will only pay out a certain amount per policy term. Once this amount is reached, they will no longer cover services.
  3. Bundled services: These clauses are in place to prevent overuse of specific codes to maximize reimbursement. If your plan has a bundled services clause and you try to bundle multiple procedures together to save time, your provider may not cover these services.
  4. Exclusion clauses: These allow insurance companies to exclude certain procedures or conditions (pre-existing conditions, for example) to save money. They will not be reversed once the contract is signed.
  5. Insufficient medical necessity: This is the least structured of any reason and provides the greatest opportunity for unjustified denials. Insufficient medical necessity is subjective and can often be overturned during the appeal process.

The first four reasons can be difficult for dental practitioners to overturn since they are relatively concrete. Once you sign a contract, it is difficult to file a successful appeal that clashes with agreed-upon terms. It is therefore extremely important to t closely before signing it—something a medical attorney can help you with.

Insufficient Medical Necessity Claims Are Different

Compared to the other most common reasons, insufficient medical necessity claim denials are much more open to interpretation and give you room to fight back. Insurance companies may attempt to delegitimize dental claims by questioning the thoroughness and practicality of procedures, even if they are procedures they would normally cover.

That does not mean the fight will be quick or easy, however. Insurance companies may be very slow to respond to these claims, hoping dentists will eventually give up. They may also use complicated legalese to try to convince you that they are justified in denying the claim.

However, by providing proper documentation and staying persistent, you will give yourself the best possible chance of winning your appeal.

Related: Do You Understand Your Healthcare Payer Contracts?

How to File Dental Claim Denial Appeals

The appeal process can be confusing and involves several steps, roadblocks, and potential pitfalls. The key to successful appeals is paying close attention to the details. However, it can be hard to know what the right steps are to take, and when to take them.

Each insurance company has its own process for filing appeals, so be sure to check your provider agreement and insurer’s provider manual for specifics. That said, many of the steps in the appeal process are similar across the industry. So, when you are ready to begin filing, the process will likely resemble the following:

  1. Review your contract with the insurance company and their provider manual: Make sure you understand why the claims were denied, as well as why exactly you disagree with the insurance company’s decisions, before beginning the appeal process.
  2. Contact the insurance company: Before you go through the process of writing an appeal, contact the insurance company. The denials may be much easier to resolve and could simply be an issue of insufficient documentation.
  3. Write an appeal letter: State your disagreement in an official letter to the insurance company. If your provider agreement and insurer’s provider manual permit it, you may be able to prepare one appeal letter for a list of denied claims – in other instances, you may be required to file individual appeals. If you are unsure how to format this letter, an attorney can help you write one.
  4. Gather documentation: Include all relevant documentation with your letter. This can include dental records, correspondence, bills, or any other information you think is relevant to the claim. The more evidence, the better your chances are.
  5. Submit appeal with documentation: Send this appeal to the insurance company for its consideration.
  6. Appeal to next level (if denial is upheld): If the original decision is upheld, it will depend on your provider agreement and insurer’s provider manual whether or not you have remaining appeals available to you. If you have no further appeals available, the contract or manual are likely to detail your remaining dispute resolution process.

If you do not feel comfortable filing appeals on your own, an attorney, like those at Bryant Legal Group, can file appeals on your behalf as well as demands for arbitration or lawsuits on your behalf. They will work with you to understand why your claims are being denied and help you file the strongest claim possible.


How to Avoid Future Claim Denials

While being able to identify claim denials that are likely to be overturned on appeal is important, it’s safe to say that most people would prefer to avoid denials altogether.

While it may not be realistic for every dentist to completely avoid any denials, knowing how to reduce the risk can save you a lot of time, money, and headaches.

To stay ahead of claim denials, consider following these tips:

  • Make sure to use the correct CDT codes
  • Carefully describe procedures using proper narration
  • Confirm the date of service
  • Understand insurance policies and plan differences
  • Understand the terms of your provider agreement and insurer’s provider manual
  • Be aware of lack of benefits
  • Ensure timely filing of your claims
  • Inform patients of potentially limited benefits
  • Document all information required by your insurance provider
  • Consider outsourcing your dental office’s billing procedures

Following these tips will not only help you keep your rate of claim denials to a minimum, but will also ensure you have the evidence you need to fight back successfully when claims are denied anyway. Due diligence and comprehensive documentation will set your claim up for success, and ensure you have protection against your healthcare payer.

Bryant Legal Group: Protecting Healthcare Providers From Unfair Denials in Chicago

Bryant Legal Group has a long history of helping dentists and other medical professionals navigate the appeals and other dispute resolution processes. We are committed to getting your dental office the help it needs to fight back against an unfairly denied claim. Our experienced attorneys are here to help you file your appeal and communicate with the insurance company on your behalf so you can focus on running your practice.

If you or a colleague believe you have had claims denied unfairly, call Bryant Legal Group at (312) 561-3010 or contact us online to schedule your free consultation today.