You must have read that many times: Claim denials are a major reason for dental practices to lose thousands of dollars each year.
But, if you look in-depth, claim denials don’t cause revenue loss. In fact, it’s the weak and inconsistent follow-up process, which fails to recover the amount your practice deserves.
When billers don’t use the right strategy, dental practices end up writing off their hard-earned dollars, which they could have easily recovered with the right approach.
If you’re facing the same issue and want to recover your dues, a strong appeal submission is the best solution.
Want to turn appeals into cash? Let’s review how appeal submission impacts a dental revenue cycle, along with the best practices to win appeals and secure payments.
What is the Impact of Appeal Submission on Dental RCM?
Appeals are letters sent by dental practices to the insurance companies to request that the payers reconsider their claim denials. The purpose is to get a claim approved and secure reimbursement.
Practices that use professional dental revenue cycle management services manage to win appeals faster and recover much of their revenue.
In fact, most of the appeals are overturned if the dental practices strongly present their case and attach complete documentation for evidence.
A recent instance is a KFF study on Medicare Advantage pre-authorization denials. 80.7% of these appeals were overturned because the healthcare provider proved that the treatment was necessary for the patient’s health. Strong documentation played an important role here.
When practices receive their due payments quickly, it becomes easy to manage the cash flow and handle all the practice operations smoothly.
However, there is a downside to it. Most denials are never appealed at all because practices either don’t know the process or don’t have the time and bandwidth to engage in the lengthy process.
And missing this important step in the back-end revenue cycle process can lead to a revenue loss of billions of dollars every year.
To protect your revenue, it’s important to submit timely appeals and recover your due payments.
What is the Process for Appeal Submission?
Review Your EOB
The appeal submission process begins with identifying the root cause of the problem and implementing steps to resolve it.
When a payer sends an explanation of benefits statement to you after a claim, it outlines everything, including the costs covered by the payer and the expenses which the patient has to pay.
It also helps you know if the payer has reimbursed the claim or denied it. And if it’s a denial, check the reason code, which is mentioned in the “Remark Code” section. You can check it to find the denial reason and start working on it.
The EOB also helps you detect underpayments when you reconcile the reimbursed amount with the contracted amount in the fee schedule.
Correct the Denial or Underpayment
The denial code helps you discover the billing error. Correct the error, whether it’s a wrong CDT code, missing documentation, spelling mistake, empty field on the ADA dental claim form, or any other discrepancy.
Use a new claim form for resubmission and mention all the correct details this time to rectify the mistakes in your previous claim.
In case it’s an underpayment, attach one copy each of your EOB and the contracted fee schedule. It proves that the amount on the EOB is less than the set reimbursement rate in your fee schedule. Doing so makes your appeal strong, and the payer is likely to reimburse your complete amount.
Prepare an Appeal Letter Template
It’s very stressful and time-consuming to create and write an appeal letter from scratch. Build appeal templates for denials and underpayments, which you can use anytime in the future. You can modify these pre-built templates according to your appeal request.
Making minor changes to a template is a smart approach rather than completely building a new one.
You can build these templates either in a document format, which you can save on your computer, or let your practice management system do the job for you. An all-in-one system that combines billing and practice tasks creates the perfect appeal templates, suited to your practice needs, payer requirements, and claim scenario.
Submit Appeal
Attach your appeal letter, along with the necessary documents, to the claim submission form, and send it to the payer. You can submit an appeal request, either automatically via the payer portal or manually via fax. Automatic appeals are sent fast within seconds, while the manual appeal takes time.
And when you have already waited enough for the reimbursement, you shouldn’t wait any longer. The payer takes time to review the appeal and pay the amount.
In that case, automation is the best solution.
What are the Best Practices for Appeal Submission?
Here are a few tips for a successful appeal submission that help you recover payments.
Use a Professional Tone
When you’re writing appeal letters, you should approach things as a professional. Your choice of words shouldn’t reflect emotion or frustration. Be respectful and courteous while requesting the payer to reconsider the initial decision.
Write a Concise Appeal
Appeals shouldn’t be unnecessarily lengthy, as the appeal review departments regularly deal with a bundle of requests. Due to the busy schedule, they can’t read lengthy pieces of text. They need just the relevant details about the claim.
So, make sure to keep your appeal to the point. It should outline all the details that are necessary for your appeal, such as the claim number, CDT code for the dental procedure, the number of the treated tooth, the date of service, the provider’s name and NPI, and the location of the practice where the service was delivered.
Attach Complete Documentation
Documents are strong evidence for an appeal submission. These documents help payers know why a treatment was needed in the first place and how it impacted the patient’s health. Attach all the pre-op and post-op documents when required, such as radiographs for diagnostic evidence.
A complete treatment narrative also helps, as it completely describes everything in a concise way. Narrative includes all the details, such as:
- Patient’s primary complaint at the time of visit
- Diagnosed condition
- Method used for diagnosis
- The treatment’s medical necessity for the patient’s health
- Treatment performed with the CDT code
Make sure that you follow the payer’s policy for required documents. You can also attach additional documents if these are strong proof.
Submit Appeals Within Deadlines
Make sure you submit appeals within your payer’s deadlines. The time limit to file appeals can be anywhere between 180 and 360 days.
For example, Delta Dental accepts appeals within 180 days after the initial claim denial.
And Medicare has five levels of appeals. Filing deadlines vary for each level. The table below breaks it down:
| Appeal Level | Appeal Type | Assigned Reviewer | Filing deadline |
|---|---|---|---|
| Level 1 | Redetermination | Medicare Administrative Contractor (MAC) | Defined in the patient’s Medicare Summary Notice (MSN) |
| Level 2 | QIC reconsideration | Qualified Independent Contractor | 60 days from the redetermination decision |
| Level 3 | ALJ hearing by the Office of Medicare Hearings and Appeals (OMHA) | Administrative Law Judge | 60 days from reconsideration decision |
| Level 4 | Review by the Medicare Appeals Council | Medicare Appeals Council | 60 days from the ALJ decision |
| Level 5 | Federal District Court | Federal Judge | 60 days from Council decision |
So, you must follow the payer’s deadlines; otherwise, the payer may not accept your appeal request, and you may have to write off the amount.
There is a rare exception, though. Some payers may accept an appeal after the deadline expires, but you must provide solid evidence for the delay.
Outsource the Process
If appeal submissions don’t work the right way, it may be because your processes need improvement, staff aren’t trained enough, or you have limited staff who are already occupied in practice tasks.
As a result, appeal submissions aren’t effective and don’t comply with payer policies. With that, payers reject appeals, and that one decision hits hard on your dental revenue cycle. You may have to write off a significant amount and give away dollars that could have been recovered easily.
Feeling worried? A professional RCM outsourcing partner, like TransDental, helps you with that. Reliable outsourcing companies are trained in managing claim denials and appeals. They deal with thousands of appeals regularly, handle multiple insurance claims, and are well-versed in different payer policies.
They also provide specialized billing services for your company, making sure your appeals are submitted correctly and you recover the complete revenue for the time you’ve invested and the hard work you’ve put in trying to restore your patients’ smiles.
These outsourcing partners manage all that for you, while you sit, relax, and provide the quality care your patients deserve.
Final Thoughts
Appeal submission is very important for dental practices to run a smooth revenue cycle and make sure cash flow is consistent. Strong and professional appeals can help recover revenue, which most practices already give up on.
But, if you manage appeals the right way, use pre-built appeal letter templates, add every detail in the letter, and justify your case with strong documentation, you’re likely to recover your hard-earned dollars!
Frequently Asked Questions (FAQs)
What is the deadline to submit appeals after a claim denial?
The deadline for appeal submission varies for each payer. Many commercial payers require practices to submit appeals within 180 days after denials, while Medicare’s deadlines are defined in the patient’s Medicare Summary Notice.
Can outsourcing help with smooth appeal submission and collection?
If you outsource dental RCM services to TransDental, we submit appeals according to payer-specific requirements and maintain professional standards. Our appeals are accurate and compliant, assisting you with quick approvals and payments, and relieving your practice staff of the burden.
How to submit dental claim appeals that payers approve?
Add all the details that a payer requires to justify your case. Attach documents to prove the necessity for the patient’s health, mention every detail concisely, and use a professional and respectful tone. Validate all your statements with evidence for a strong appeal that gets overturned.
How to build an appeal letter template?
Use an all-in-one practice management software to build appeal letter templates, which create placeholders for essential information like the date of service, CDT code, claim number, patient’s insurance ID, provider’s NPI number, practice address, and other details. Pre-built templates save time and can be modified for each appeal.
