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ADA/NADP share views on claims payment concerns

This is the fourth installment of a series of ADA News articles on dentists' "Top 10" concerns submitted to the ADA about their dental claims. These articles include perspectives from ADA members, National Association of Dental Plans members and the Council on Dental Benefit Programs.

Lost radiographs, claim forms and attachments were among the most frequent concerns ADA members complained about to the ADA during 2005.

Dentist and dental benefits industry perspectives on claims processing delays were covered in the March 5 ADA News. Dental claims denials were featured in the Nov. 20, 2006, and Jan. 8 ADA News.

Subsequent articles will feature the remaining "Top 10" concerns which include bundling and down-coding, post utilization review, assignments to participating doctors only, provider contract issues and others.

Dental Claims Denials
Lost Radiographs, Claim Forms and Attachments

Dentist perspective

One of the biggest complaints concerning third-party claim payment is lost claims and lost X-rays. Many dentists report sending in claims or X-rays several times before the insurance company will acknowledge receipt. Often X-rays are submitted with the claim, but the dentist will receive an explanation of benefits requesting the X-rays.

Confusion often arises due to the lack of standardization for attachments from carriers and the inability to reference attachment requirements for multiple carriers in a central location. This mandates that each office contact each carrier individually to determine what is needed to adjudicate the claim. In the absence of definitive information, the dental office often submits additional attachments to avoid possible delays in payment by a subsequent additional request.

The Council on Dental Benefit Programs notes that there is no uniformity within the payer community regarding submission of radiographs, partly due to different business structures within the industry. Some companies would prefer that no radiographs be sent unless they are requested. Others want to see images at the time specific procedure codes are reported.

The council says that the underlying concern from the industry perspective is based upon a cost versus benefit relationship. Is the additional cost for having the radiographs sent with a claim and then returned offset by a savings gained by reducing potentially fraudulent claims? Each company makes these and other similar decisions on its own. This proprietary information can help determine the profitability of any given payer. When bidding for contracts it provides some companies with a competitive advantage. For this reason, payers do not share this information, and this is why standardizing of third parties' handling of claims is such a daunting task. The more things become standardized, the more each company looks alike, and the harder it becomes to distinguish them in the marketplace.

If X-rays are submitted together with a paper claim, how do they get separated? What happens to all those lost X-rays? In addition, many electronic claims submissions require attachments to be mailed separately because of dental offices' inability to scan paper forms and standard radiographs through the practice management software. This delays claim processing and increases the risk for error.

Many dentists think that losing claims and X-rays are delay tactics used by third-party payers in order for them to meet financial or claim processing goals. Although claims processing delays have a cost to payers as well, some dentists believe that the financial benefit to payers outweighs those costs.

Dental benefits industry perspective

Some X-rays and claims may be lost from the sheer volume of handling 250 million claims annually. About 70 percent of all claims are submitted on paper. Paper processes require manual systems that can fail. Mistakes are inherent in all systems.

Carriers have introduced a variety of systems to reduce the paperwork of claims and minimize mistakes such as lost attachments.

These include:

  • scanning all paper and X-rays into electronic systems;
  • reducing or eliminating the need for submission of X-rays;
  • establishing auto-adjudication systems;
  • promoting the use of electronic transactions.

Additionally, in response to discussions of the ADA/NADP Joint Working Group on Radiograph return, NADP recognized the difficulty for a dental office keeping track of varied carrier attachment requirements. NADP worked with a commercial vendor, National Electronic Attachment, to create a single Web-based portal where carrier attachment requirements can be accessed. The portal, called FastLook, was launched in January 2007 at "". For information on NEA services call 1-800-782-5150.

In some instances, the method by which claims are submitted increases the possibility of loss. Attachments that are not firmly affixed to a claim form can get separated when the mail is opened; this is especially true when multiple claims are submitted in one envelope. If X-rays are not labeled and get detached from claims, they cannot always be matched back to the appropriate claim form. Privacy and security standards require that personal medical information be protected, so unmatched attachments would most likely be destroyed.

When a payer does not require an X-ray for a claim, the process established by that payer may require that the X-ray be removed and returned or destroyed. If a subsequent issue removes the claim from auto-adjudication for review, an X-ray may be requested at that time.

Submitting electronic claims and the appropriate attachments to them is the best way to avoid the loss of claims, X-rays and other attachments. Many of those offices that do submit claims electronically do not have the equipment necessary to submit X-rays as electronic attachments. Given this circumstance and the fact that some 60 to 70 percent of dental claims are still submitted as paper correspondence, it is important that payers and dentists develop processes to minimize the potential of lost claim forms and attachments. 
Compiled by Arlene Furlong