When Dental Insurance Doesn’t Pay

In our 3rd and final installment of how Jones Family Dental helps our patients with their dental insurance, we will discuss how to manage the problem of insurances not paying for needed patient services.

Many times insurance claims aren’t paid right away. Sometimes they send a denial letter or sometimes they offer no response at all. There are some obvious advantages for an insurance company to delay payment most of which involve profits. As far as the reasons for the delay or denial that they offer, here is a brief list:

  • Insurance companies saying they never received it
    • We often resubmit the claim via fax or email
  • Treatment record discrepancies
    • This usually is associated how we describe or label certain treatments either in a your history or during current treatment
    • We call and then resubmit
  • Identity or Plan number discrepancies
    • This is where it is crucial to get us all of your current and accurate data to allow us to advocate for you with your insurance company
  • More information or narrative required
    • We jump through numerous hoops to prevent this from holding us up
      • Intra oral picture
      • X-ray attachments
      • Detailed narratives of findings
      • Sending this data via mail, email, and or fax
    • Secondary Insurance vs. Primary Insurance
      • If you have two plans it is often a little more work to make sure that we get both plans to pay for your services
    • Patient Inquiry
      • Often the insurance company is trying to communicate directly with the patient regarding status or services provided.

Once in a while a claim is denied with “no good reason” or that service is simply “not a part of the dental plan that was purchased.” We’ve seen some crown claims or periodontal claims come back denied with only a sentence from the insurance stating that “the work is not necessary,” even if proof was shown in the first place. When this occurs, as a service to you we work as your advocate by:

  • Writing an appeal letter
    • This is usually all it takes to get results
    • It may be 30 days before we receive a response to this letter
  • We may resend the claim with all of the x-rays, digital photos, and chart notes
    • About 70% of the time an appeal for covered services will be approved and the claim will be paid.
  • In cases where the service is not a part of the patient plan we include a letter asking for special consideration.
  • If the claim is still denied after all of our efforts we will invite the patient to write a letter directly to the insurance company
    • We will act as a consultant in that scenario in order to help the patient make their case for reimbursement
  • Unfortunately, if all appeals are denied, the patient is responsible for the remaining balance of the visit but we may be able to work with the patient on a case by case basis.
    • We are constantly updating our system to better predict what certain plans are doing to avoid payment so when this happens we take note and try to avoid this problem in the future.

Insurance is confusing and it is very important to read through your coverage benefits. It is disappointing to see patients receive care and then have it denied due to a fine print clause like a waiting period or frequency limitation. We are here to help you understand your plan and will do what we can to know as much as possible prior to treatment. We are happy to go through your plan with you, and if there are any questions we cannot answer, you will be directed to your dental insurance company. This is yet another area where we partner with our patients to improve and maintain your dental health.