Claims Processing Delays | American Dental Association

Claims Processing Delays

Top 10 claim concerns: ADA, NADP share views on dentists' concerns

The ADA Council on Dental Benefit Programs continually receives and addresses a variety of dental claim submission and adjudication questions from member dentists and practice staff. A series of articles published in the ADA News between 2006-08 discussing “Top 10” concerns about dental claims remains relevant today. The articles included perspectives from ADA members, National Association of Dental Plan members and the Council on Dental Benefit Programs.

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.

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 www.neafast.com. 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.