strategies for managing unpaid claims

Dental RCM and Collections: Strategies for Managing Unpaid Claims

If you’re a dental practice owner, collections related to medical services are often overlooked. But they can have a significant impact on your bottom line. If your practice hasn’t considered collecting unpaid claims as part of its revenue cycle management strategy, it’s time to start. Several strategies can help manage unpaid claims effectively, including using online portals, ensuring timely follow-up with patients and providers, and working with third-party companies.

What Is Dental RCM?

Dental revenue cycle management is the set of processes and procedures implemented to manage a dental practice’s financial flow efficiently. This encompasses patient payments and insurance reimbursements to maintain a steady and robust revenue stream. The success of these processes is crucial for the practice’s financial stability, as it directly affects its cash flow. 

Dental RCM And Collection 

Dental revenue cycle management (RCM) and collections are closely related because they impact a dental practice’s financial health. For example, a crucial aspect of dental RCM is ensuring that all insurance claims are submitted accurately and on time. Any errors or delays in the claims submission process can result in denied or delayed payment from insurance companies, directly affecting the practice’s collections.

The practice may implement strategies for better insurance verification, proper coding, and efficient claims submissions to mitigate this issue. This will help to increase the likelihood of timely and accurate payment from insurance companies, improving the overall collections for the practice. Thus, dental RCM and collections play a crucial role in the financial health of a dental practice and are interdependent.

Understanding the Root Causes of Unpaid Claims

Identifying and preventing the most common reasons is important to minimize the financial impact of denied claims. The primary causes of denied claims are:

Lack of prior authorization – The claim may be rejected if the necessary authorization is not obtained before providing the service.

Incomplete or incorrect information– It can include missing demographic information, incorrect plan codes, or technical errors.

Failure to meet medical necessity requirements – Services deemed medically unnecessary are typically not covered by insurance policies. The claim may be denied if the payer and physician disagree on what is necessary.

Procedures not covered by insurance – This issue can be easily prevented by reviewing the patient’s insurance plan or contacting their insurance provider before submitting the claim.

Out-of-network provider – If a provider performs the service outside the patient’s network, the payer may reject all or part of the claim.

Duplicate submissions – If a claim for a single encounter is submitted multiple times by the same provider for the same patient for the same service item, it may be rejected.

Coordination of benefits issues – When patients have coverage from multiple health plans, their claims may be delayed or denied until their benefits coordination is updated.

Bundling – In some cases, insurance companies may group them instead of paying for separate services and paying a lower fee.

Services included in other payment – If a service is included in the payment or allowance for another service or procedure that has already been processed, the payment for the separate service may be adjusted.

Timely filing limit exceeded – Claims submitted outside the required time frame set by the payer may be rejected. So it’s essential to file the claim in the required time frame.

By being aware of these common reasons for denied claims, dental practices can take proactive steps to prevent them from happening and minimize the financial impact.

Strategies For Managing Unpaid Claims

Collecting unpaid claims is essential to managing risk—and should be implemented regardless of size or scope! Several strategies can help you manage unpaid claims effectively, including using automated tools, ensuring timely follow-up with patients and providers, tracking the claims, and working with third-party companies.

Using Automated Tools

Adopting more automated claim denial management systems can simplify the process of adhering to various payer codes and policies. This software can streamline staying current with diagnostic codes and insurance regulations. It can free up time for your billing team to thoroughly review claims and ensure compliance with all requirements. By providing providers and billing teams with access to claim denial data, organizations can establish benchmarks for denial rates and develop strategies for improvement. 

Keep The Process Organized 

Maintaining an organized system is crucial to avoid financial loss and administrative issues caused by missed denied claims. Establishing a structured denial management process that utilizes HIPAA-compliant tools and technologies to track submitted claims is essential.

Track and Analyze Denials

Track, evaluate, and record denial trends by categorizing them. Utilize data and analytics to uncover the root causes of denials and work to address these issues by seeking help from physicians, payers, or outsourcing partners. This approach will aid in reducing denial rates and enhancing compliance.

Act Swiftly

To correct denials, follow a proven process and aim to resolve them within a week. This can be achieved by having a well-defined workflow that tracks claims as they move through the system.

Form a Dedicated Team

Utilize the expertise of various departments to establish solutions and track progress, setting benchmarks, reducing backlogs, and identifying underlying issues. The team should consist of crucial representatives from admitting/registration, case management, patient financial services, nursing, health information management, information technology, finance, compliance, and physicians.

Track Progress

Continuously monitor progress to determine which areas are performing well and which need improvement. Automating denial management processes can also free time to focus on correcting rejections.

Conduct Performance Reviews

Regularly perform audits of remittance advice, write-off adjustments, zero payment claims, registration, and insurance verification to ensure quality.

Conduct Follow-Ups

Regularly track each claim to correct and resubmit denials and rejections on a scheduled appeal, avoiding financial loss.

Adopt a Decision Tree Method

The decision tree approach considers all possible outcomes and concludes by following each path. This helps train staff to handle denials more efficiently.

These tips will help you effectively manage your revenue in your dental practice, which is both a place for oral healthcare and a business. The choice of an outsourcing partner is a crucial decision for any practice. A professional dental billing company will ensure its staff is knowledgeable about current billing practices. Consider using Dental Revenue Group as an outsourcing partner to tackle the difficulties of achieving efficient reimbursements, maximizing upfront patient payments, and streamlining the revenue cycle process. This provides access to a team of experienced professionals who focus on communication with insurance companies and understanding the root cause of rejections and denials. Utilizing our dental billing and RCM services can free up internal teams to concentrate on other essential aspects, such as patient care and facility management. It can improve the financial performance of your practice and help you achieve greater profitability.

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