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Authorization and Getting Paid, lesson 2 of 4
Getting Paid by Denti-Cal Without Losing a Month
Most denied dental claims are not clinical arguments. They are eligibility and documentation problems created before the patient sat down, which is good news, because that is the part you control.
- Check eligibility. On the day, every time, for everyone
- Document while treating. Not at the end of the week
- Work denials weekly. A fixed hour beats good intentions
- Appeal. When the treatment was right and the paperwork was thin
The Front Desk Decides Whether You Get Paid
Coverage changes. A patient who was eligible in March may not be in April, and nothing about the appointment will tell you that. Checking on the day of treatment, rather than when the appointment was made, removes a whole category of denial.
Make it part of the morning routine for the whole schedule rather than a thing somebody does for new patients.
Write the Note That Supports the Claim
Denials for insufficient documentation usually mean the treatment was justified and the record did not say so clearly. The x ray existed, the note was thin, nobody connected them.
Write the reason at the time, in the record, in plain clinical language. Reconstructing it six weeks later is slower, weaker and sometimes impossible.
Give Denials a Standing Hour
Denials get worked when somebody has time, which means they get worked never. Put a fixed hour in the week with a named person and a list.
Sort the list by how old each one is. Appeal windows close, and a good claim that aged out is the most annoying way to lose money there is.
Know Which Ones to Fight
Appeal when the treatment was clinically right and the paperwork was the problem, because that is the one you win. Appeal when a code was misread. Appeal when eligibility was actually in place and the check said otherwise.
Do not spend an hour on a small claim that was genuinely not covered. Knowing which is which comes from tracking your own denial reasons for a few months.
Count Your Reasons, Not Your Claims
Every practice knows its denial rate. Far fewer know their top three denial reasons, and that is the number that tells you what to fix.
Three months of counting usually shows that one or two causes produce most of the problem, and both turn out to be a habit rather than a policy.
Before You Spend a Dime
What is a reasonable denial rate?
Rather than chase a benchmark, track your own rate and your top reasons month to month. The trend is more useful than the number.
Should we outsource billing?
It can work well for a small practice with no billing specialist. Ask any biller for their denial rate and their appeal rate, and ask how they report back to you.
How long do we have to appeal?
Time limits apply and they vary. Get the current windows from the program and put them in your workflow.
Next Problem to Solve
- A Denial Is Almost Always a Document ProblemNext in the course. How to read a denial, sort the ones worth reworking from the ones that are telling you something, and stop the same denial from arriving again next month.
- Choosing Dental Software When Many Patients Are on Medi-CalRelated. What to test in dental practice software when a large share of your patients are on Medicaid dental, and the questions demos never answer.
- Enrolling as a Medi-Cal Dental ProviderRelated. What enrolling in Medi-Cal dental involves, what slows applications down, and what to sort out before you start.
- Should Your Practice Take Medi-Cal PatientsRelated. A plain look at the economics of Medicaid dental for a private practice, and how some offices make it work.