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Dental-Medical Cross Coding
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Checks and Balances
By Marianne Harper

Are you certain that you have received the full insurance benefit from all of your closed claims? We are often so concerned with the front side of insurance claims – filing the claim - that little attention seems to be paid to what I call “the back side” of claim filing. The back side involves the steps that need to be followed when insurance benefits are received. Unfortunately, it is never as simple as just posting the payment and depositing the check.

A system should be developed within each practice to insure that all dental claim payments are handled in the best interest of both the patient and the practice. Staff members need to be cognizant that errors could have been made either by the insurance carrier or within the practice. If claims are not proof-read prior to mailing or submitting electronically, it is likely that errors will occur on some of these claims. Even with proof-reading, there can still be a small risk of error. Staff members need to always be mindful of this when posting these payments.

Checking for errors on claims is just part of a full claim payment monitoring system. The system that is suggested in this article is titled POST WITH CARE and involves the following:

Post the payment. Care should always be taken that the correct claim is chosen to assign benefits to. Posting to the correct date of service is very important because, when a benefit payment is posted to the wrong date of service, it will be difficult to determine why the non-chosen claim is still outstanding. This usually will not be discovered for quite awhile and the insurance carrier will report that the claim had already been paid when an inquiry is made. This slows down the receipt of practice revenue and may cause patient dissatisfaction if he/she is billed for what insurance has not paid.

Obtain blue book values. Most practice management software systems provide for a way to assign the usual and customary fees of third party carriers (blue book values) to the practice’s transaction codes. This helps practices estimate coinsurance dollars for patients both at checkout and on treatment plans. While posting insurance payments, if a conscientious effort is made to record the fees for the different procedures that you perform, you will find that you will eventually have a strong list of each carrier’s UCR. Patients should always be required to pay their full coinsurance and copays at the time of service. When your practice can give an accurate estimate of coinsurance, your billing costs will be reduced because fewer statements will have to be mailed and you will generate more revenue at the time of service.

Secondary claims. When your practice receives a payment from a primary carrier, check to make sure that a secondary claim is generated. If the secondary claim is through a managed care plan, be certain that the primary hasn’t paid more than the secondary carrier would pay. If it has, void the secondary claim and make any required adjustment to the account. There is no point in paying a fee for submitting a claim to a carrier that you know will not pay any benefits. When you receive payment from the secondary carrier, be certain that they have paid as a secondary carrier. There will be times when the secondary does not have information about the primary and will pay as primary. When this happens, inform the secondary carrier so that they can obtain the correct information from the insured and request a reimbursement from your practice.

Total the fees on the claim. Always make sure that the total of fees on the EOB is the same as the total of the claim that you submitted. Third party carriers can omit procedures in error. You will not know that this has happened unless you consistently check the totals.

Write offs. If your practice has contracted with any third party carriers, each claim must be reviewed to make sure that any required adjustment has been made. Patients must not be billed for any amount over the contracted fee.

ID numbers. When a denial of eligibility is received, always compare the patient’s ID# that appears on your copy of his/her insurance ID card with what has been entered in the computer record. A data entry error could have been made. Never just assume that there is no coverage and close the claim just because you received a denial.

Treatment Plans. Pay close attention to what any claim payment does to the patient’s account balance and handle accordingly. If an insurance payment creates a credit on an account, don’t refund this credit until you check to see if there is treatment pending for any family member listed on the account. If treatment is scheduled, hold the credit to use against those fees. If there is no scheduled appointment, seize this opportunity to contact the patient and see if he/she would like to schedule and use this credit towards those fees.

Handle bundling. Some third party payers bundle procedures. If you receive an EOB where this has been done, make sure that the total of the fees is accurate. If you find such an error, contact the carrier and require a correction.

Check the name of the patient. Third party carriers have been known to pay benefits in the name of the insured when the patient was actually a dependent. Make a practice of checking the name of the patient on the EOB to be sure it is the same as the name of the patient who received these services. If this type of error is discovered, you must contact the third party carrier to advise them of this so that they can make the necessary changes. If this is not done, it will impact the patient in whose name the benefits were paid by not paying benefits when a similar claim is submitted for him/her. In addition, third party carriers might pay decreased benefits when they process a claim with the wrong patient.

Assign special informational notes to third party carriers. If your practice management software provides a means for attaching such notes, make it a practice to use them. Unique plan information can be posted on these notes and be accessible when checking out patients or when treatment plans are proposed. These notes will help you establish a more accurate estimate on coinsurance.

Research denials. Third party carriers will list codes that represent their reason for denials. Determine the reason and take action. If there is a coding problem, get some help. There are excellent sources of help available. “Insurance Solutions Newsletter” is just one example (888-825-0298). If your practice subscribes to this newsletter, phone support is available for insurance filing questions. Also, some carriers will delay payment because they require additional information from the subscriber. Document this and contact the insured if the claim remains unpaid.

Each day, send patient statements. This is the last and possibly most important step to this system. Daily statements mean that a statement will go out immediately after claim payment. When statements are mailed once or twice a month, revenue will be strong at that time and weak during the remainder of the month. The beauty of this aspect of the system is that it will greatly improve practice cash flow.

Establishing and following strong systems is a key to efficiency and prosperity in dental practices. For practices that file insurance claims for patients, it is imperative that staff members conscientiously adopt a system such as POST WITH CARE to insure that, when a claim is closed, it is correctly closed. This will help both the practice and patients obtain the maximum insurance benefit on a timely basis and cut those hidden costs of that Accounts Receivable.


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