Medical Billing for Dental Implants: Best Practices
Medical insurance billing for dental implant services is one of the most complex and challenging processes in the medical reimbursement arena. Dental implant reconstructions require a high level of clinical expertise on the clinician’s part and involve high-tech diagnostic and treatment “armamentariums.”
On a per arch basis, dental implant services are lower in cost today compared to 20 years ago but, even with cost reductions due to time efficiencies, implant reconstruction procedures are still costly for the patient. For patients with documented medical necessity, the cost of reimbursement can be shifted to the private insurance pool where the patient may have 80-90% of the service covered by their medical carrier. For this reason, it behooves implant providers to at least be familiar with what’s possible in medical billing for these services.
One assumption made for this article is that after researching your local market and choosing which carrier has the most policyholders, the practice enters into a legal agreement to be part of the PPO network of the medical insurance reimbursement entity. Many policies either pay less on a percentage basis or completely exclude reimbursement provided outside the PPO network. As this task can be daunting for providers, getting professional assistance is likely to handle the documentation and paperwork required by the carrier.
This article is designed to help dental implantologists understand the best practices for successful insurance billing, as well as the most common challenges faced.
Dental Implants & Billing
The most important components of medical billing for dental implant services include:
1. Accurate Documentation:
One of the primary challenges in medical insurance billing for dental implant services is ensuring accurate documentation. Clear and comprehensive documentation is crucial to substantiate the necessity of the procedure and support the claims submission process. Providers must meticulously record detailed patient histories, diagnostic images, treatment plans, and progress notes. Additionally, it is important to include relevant medical records and any pre-authorization forms required by the insurance provider. By maintaining accurate and thorough documentation, dental practices can minimize claim denials and expedite the reimbursement process.
Common pitfalls for providers include: not providing specifically what the insurance carrier requests to be submitted for records or submitting documentation in a manner that the carrier won’t accept the submission. These errors are universally made by most providers not using professional claims submission services familiar with the specific insurance carrier.
2. Insurance Verification and Pre-Authorization:
Insurance verification and pre-authorization play a vital role in medical insurance billing for dental implant services. Prior to providing treatment, dental practices must verify the patient’s insurance coverage, ensuring the specific implant procedure is covered by the patient’s plan. Understanding the insurance provider’s policies, limitations, and requirements is crucial to avoid claim denials. Obtaining pre-authorization is often necessary for dental implant services. Dental providers just submit the required documentation, including treatment plans and relevant records, to the insurance provider for review and approval. Prompt and thorough communication with the insurance company can help in expediting the pre-authorization process and minimize delays or rejections.
Common pitfalls include: Lack of documentation from a physician who has diagnosed health conditions that provide a medical necessity for treatment with implants and a lack of written communication to the insurance carrier by the physician performing the diagnosis and who attests to the conditions that warrant dental implant treatment. Pre-authorizations written by a diagnosing physician who is inside the insurance carrier’s network are far more likely to be approved than those written by the dental provider or by an ‘out of network’ physician.
3. Proper Coding and Billing:
Accurate coding and billing are critical to maximize reimbursement for dental implant services. Dental implant providers or a professional claim submission company must assign the appropriate Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes for the procedure, ensuring they align with the patient’s diagnosis and treatment. It is important to stay updated with the latest coding guidelines and any changes implemented by the insurance industry. Dental practices should also ensure that all required fields on the claim forms are completed correctly to avoid claim rejections or delays. Regular training and education for the billing staff can help in maintaining coding accuracy and compliance with insurance guidelines. Unless a practice plans to submit hundreds of claims annually, hiring a professional claim submission entity to handle this ever-evolving part of billing is far more efficient.
Common pitfalls: Attempting to be proficient at billing too many carriers or not understanding when it’s better to outsource the claim submission process. If the provider isn’t going to bill hundreds of arches per year, it’s more efficient to simply use a third-party service to handle claim submission and follow-up.
Additionally, it’s important to understand your local state and regional insurance market and to focus only on the carrier that makes the most sense. Who is the #1 private medical insurance carrier in your region? How many beneficiaries are there? What is the coverage with medical necessity after deductibles are met for the leading carrier in your region? Based on this information, does it make sense to even be considering?
4. Timely Submission of Claims:
Submitting claims in a timely manner is essential for efficient reimbursement. Dental practices should establish a streamlined process to submit claims promptly after the completion of dental implant services. Delays in claim submission can result in potential revenue loss or claim denials. Utilizing electronic claim submission methods can help in reducing processing time. Regularly monitoring claim status and following up on pending claims is crucial to identify and resolve any issues promptly. By maintaining a proactive approach to claim submission and tracking, dental practices can ensure timely reimbursements.
Common pitfall: As pre-authorizations are critical to predictable claim payments, it’s important never to start a case before that step has been handled.
5. Effective Denial Management:
Claim denials are a common challenge in medical insurance billing for dental implant services. Dental implant providers should implement an effective denial management strategy to handle denied claims promptly and efficiently. Analyzing the reasons for denials and addressing them through accurate documentation, coding improvements, and communication with insurance providers is crucial. Dental practices should appeal denied claims with appropriate supporting documentation, ensuring compliance with insurance policies and guidelines. Regularly reviewing denial patterns and implementing process improvements can help in reducing the frequency of claim denials and optimizing revenue.
Common Pitfall: The biggest reason practices stop attempting to bill private indemnity medical insurance for dental implant services is due to denials. If claim denials are happening in more than 20% of claims submitted, consider moving to a professional billing entity.
Medical insurance billing for dental implant services presents its share of challenges, but dental implant providers can overcome them by implementing the best practices outlined in this article. Accurate documentation, insurance verification, pre-authorization, proper coding and billing, timely claim submission, and effective denial management are essential components for successful medical insurance billing.
Beyond these details, understanding one’s local market to target the carrier with the most policyholders, abiding by carrier rules to be ‘in network,’ and making sure that medical necessity documentation is handled by a diagnosing physician who is also in network with the carrier are important ingredients for success with billing.
Those willing to take these actions can help patients with medical necessity needing implant services utilize policies that can reimburse 80-90% of treatment costs while helping these patients enjoy the benefits these advanced clinical services bring to their daily lives.
If you want to have a one-on-one discussion about all of this, schedule a time to discuss at www.meetme.so/jamesmcanally.