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Trojan Today Classic: “Advocating Insurance for Your Patients” by Roz Fulmer

Originally published 2013

Advocating insurance for your patients can be fun! Want in on the secrets? 

Secret #1

Play the game! Yes, it is a game of chance. Will the insurance company pay this claim or not? Is this claim free of any errors? Is there any cause on this claim that might motivate the insurance carrier to delay your reimbursement? The number one reason insurance claims get denied or postponed for payment is an error on the claim form, usually in box #13 (Date of Birth), #15 (Policyholder ID or SS#), and/or #39 (Number of Enclosures – needed if procedures require x-rays and/or photos). Are you updating your software each day when you receive the report from your healthcare claims clearinghouse which includes errors that were on current claims?

Secret #2 

Play nice! When speaking with an insurance call center person, speak with respect. Did you know your body language can come across the phone line? Talk to the representative like you would talk to your best friend and they will be glad to help in most cases. Thank them for their help in advance and you will be pleasantly surprised how much information you will receive towards processing your unpaid claim. At the end of your conversation, ask what could have been done differently to get this claim processed correctly the first time. Thank them again for their time and help in getting this claim processed for the subscriber (your patient). Kindness and respect work every time!

Secret #3

Ensure quick claim processing! Know which procedures will process through the system more quickly if you send the appropriate documentation and narratives beforehand. Do they know “why” the treatment was done, the defects of the tooth? Does this patient have any medications and/or medical conditions that could be a problem if this treatment were not done? What “evidence” (x-rays, photos, etc.) is being sent to validate the necessity of the procedure for the patient? 

In the very near future, our dental coding system will undergo a change; insurance companies will not want any narratives on claims once electronic health care records are implemented. Most codes will have an additional diagnosis code as well as the procedure code like medical coding has now. An example is a diagnosis code (ICD) will be created 

in dental for relief of pain and then we will also submit the procedure code like we currently do.

Secret #4

Code correctly! Dentists have a legal obligation to report the code that best describes the procedures they performed, not the code that will be paid. Knowledge of the procedures and understanding of the ADA codes are a must for all team members in the practice, not just your insurance coordinator. Often overlooked by the dentist is the fact there is a learning curve for the business team members when the CDT codes get revised every two years. We have to learn how to present the benefits of these procedures to the patients and to share what the changes may mean towards their reimbursements by their insurance plans.

Secret #5

Train! When was the last time you held a team meeting on the topic of “Understanding the CDT Procedure Codes Correctly”? If you need an agenda, please call me at 815-481-3851 and I will be happy to email one to you. Do you know how many examination codes your practice could be submitting to insurance plans? Do you know when to submit the code D9110 for Palliative Treatment versus using the Limited Evaluation code D0140? These are only two areas of coding training that should be covered on a regular basis at a team meeting. Support your insurance coordinators with continuing education courses that are offered at local and national dental meetings. Hire a professional trainer to come to your practice to help train you and your entire team in coding correctly in order to get maximum reimbursement for your patients and your practice.


Roz Fulmer


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