Reducing Unpaid Insurance Claims While Getting the Most Benefit Possible for the Patient

Emily Shelton, with text, "Real-world insights from AADOM authors"

Insurance: the word that no one likes to talk about, much less deal with. In the healthcare field, attitudes about insurance and its benefits can make or break the process of practice.

With the ever-increasing cost of healthcare, it is especially important to help your patients get the most out of their plans and benefits.

Today, the role of insurance and billing is constantly changing in an office. It is beneficial to the patient and the practice alike to have a team with good knowledge of how it comes together.

Each plan has certain parts that are unique.

Providing the correct information

A lot goes into filing a claim correctly. It starts with the accuracy of inputting the insurance information and the evaluation/consultation of the procedure required.

Even with the most thorough reviews of insurance information, there are occasionally denials that come back for certain reasons. Entering the correct information for the insurance is key.

For example, the following information has to be considered:

  • The correct active insurance.
  • The correct remit address.
  • Valid payor ID (for claims submitted electronically along with NEAs/National Electronic Attachments).
  • Subscriber name (insurance policy holder) with their date of birth and relationship to the patient. If they are not the subscriber, also include the patient full name along with their date of birth.

Clinical notes and documentation

Especially important aspects of the claim should include the correct coding of the procedure being performed and proper documentation to support it. Coding comes from the doctors/assistants during the initial visit where the patient’s proposed procedure is planned.

After treatment, documentation is required to explain each detail of the procedure performed. This information becomes a narrative for the record, to help support the proper treatment plan and reasoning for such services.

Insurance companies need documentation from the providers to prove the necessity of the procedure and make a correct determination of the benefits.

In other words you’re showing why the benefits are in line with the procedure(s) performed.

What if the claim is rejected?

Claims can be rejected for several reasons. It is our responsibility as the provider to review and resubmit them for the benefits to be released. There are multiple scenarios where it’s normal to get denials on the explanation of benefits from insurance companies.

It could be as simple as incorrect data on the insurance information, an x-ray was needed to see the tooth/teeth involved, omitted notes, a special narrative, and coordination of benefit issues.

Or simply, treatment may not be covered or the patient has maxed out on the plan’s limitations. The Long-Term Payout If the correct claim and information is not given to the insurance company up front, it will prolong releasing any type of benefits to the patient and provider.

When completed correctly and accurately, claims processes will benefit both patient and provider alike.

You will not have as many unpaid claims and you will be able to bill your patients sooner for any remaining balance on their account. Additionally, the patient will receive their statement in a timely manner.

Improved efficiency will give providers a handle on accounts receivable to keep unpaid claims to a minimum.

Meet the AuthorEmily Shelton smiling in a black dress outside

Emily has over 10 years of dental office experience and is passionate about her role as an insurance billing coordinator.

She says the favorite part of her job is helping patients understand and get the most from their benefits. Emily has been an AADOM member since 2019 and is a member of AADOM’s Tennessee Valley Chapter… Opens in a new window to aadomchapters website… .

In her free time, Emily enjoys swimming, cycling, and motorcycling. She makes it a mission to live out her favorite bible verse, “Do to others as you would have them do to you”.(Luke 6:31)

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2 comments on “Reducing Unpaid Insurance Claims While Getting the Most Benefit Possible for the Patient”
  1. Avatar
    Marco Bruce

    What an inspiring and helpful article. Thanks a lot!

    Reply
  2. Avatar
    Bruce Samson

    Really helpful and interesting blog! Keep it up!

    Reply
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