There is many dental practices that tell patients, “We don’t file medical insurance.” But, in most of these cases, that statement isn’t really about eligibility, and it’s more about complexity. The thing is, medical billing for dental procedures is fundamentally different from traditional dental billing. And because of this a lot of practices avoid it entirely. But they may be leaving significant revenue on the table because it’s this decision.
Today we will go over the following;
The difference between dental and medical billingWhen dental procedures may qualify for medical insuranceWhy practices avoid medical billingThe financial impact of denied or unsubmitted claimsHow outsourcing medical billing can increase collectionsDental Billing vs. Medical Billing and What’s the Difference?
The thing is dental practices are structured around dental insurance workflows. Now what does that mean? It means CDT procedure codes, Dental-specific claim forms, Routine preventive and restorative coverage models, and Limited medical necessity documentation requirements. But on the other hand medical billing, operates under an entirely different system of CPT procedure codes, ICD-10 diagnosis codes, CMS-1500 claim forms, Strict medical necessity documentation, Payer-specific policies and timelines, and Formal appeals processes.
When submitting medical claims you get to have an understanding of diagnosis-driven reimbursement, pre-authorizations, the coordination of benefits, and the compliance standards that actually differ from dental insurance. Naturally, this for most dental teams is not a part of their training. And that is why many of these practices choose not to file medical insurance at all.
When Dental Procedures are Billed to Medical Insurance?
A lot of practices are unaware that many dental-related procedures may qualify for medical insurance reimbursement when they meet medical necessity criteria. For this the most common examples are:
- Oral surgery due to trauma or pathology
- TMJ treatment
- Sleep apnea appliances
- Biopsies and oral pathology services
- Medically necessary extractions
- Hospital-based dental procedures
The challenge in these cases is not about whether these services actually qualify, but it is more about if they are coded, documented, and submitted correctly. You need to understand that without proper ICD-10 diagnosis linkage and supporting documentation, even eligible services are quite often denied.
Why Many Dental Practices Avoid Medical Billing
There are a lot of operational reasons as to why a lot of dental practices avoid medical billing.
Lack of Staff Training
The medical coding that is needed is a different skill set than dental coding. Most of the dental front-office team members are not really trained in ICD-10 diagnosis selection or these medical claim submission protocols.
Fear of Denials
There is also the fact that medical claims are scrutinized more heavily than dental claims. If you do not have expertise, the denial rates can be high.
Time Constraints
For submitting, tracking, and appealing medical claims you need to keep following up. This is something that a lot of practices do not have the capacity for.
Previous Negative Experiences
There are some practices that attempt medical billing internally and end up experiencing delays, denials, or compliance concerns. But instead of restructuring their billing process, many such practices just opt out.
The Financial Impact of Avoiding Medical Billing
If you choose not to file medical insurance, that does not really eliminate the complexity, it just end up shifting the cost elsewhere.
The most common consequences would be:
Lost reimbursement for eligible procedures
Increased patient out-of-pocket costs
Reduced case acceptance
Higher write-offs
Missed appeal opportunities
Increased accounts receivable aging
After some time, even a small percentage of these uncollected medical claims can represent a significant revenue leakage.
A lot of practices underestimate just how much revenue is actually tied to the medically billable services.
The Medical Billing Denials Management
Medical billing denials management is the process of investigating denied claims, identifying root causes and correcting coding or documentation issues in way that is structured.
Preventive strategies to reduce future denials
If you do not have an organized denial management process, these denied claims often go unworked. This end up resulting in revenue loss that could have been prevented.
How Apex Claim Solutions Helps Dental Practices Increase Collections
Here, at Apex Claim Solutions, we specialize in providing medical billing and denials management services for dental and specialty practices.
We help in supporting these practices by helping to identify services that qualify for medical billing.
We review the denied or unpaid claims, help in correcting the coding, documentation, and eligibility issues.
Our team helps in managing resubmissions and appeals and reducing the denial rates with our proactive workflow improvements.
Outsourcing the medical billing to specialists is actually a great way that practices can improve reimbursement rates, reduce administrative burden, etc.
Should Your Practice be Reconsidering Medical Billing?
If at this time your practice says, “We don’t file medical insurance,” it may be worth evaluating the why of it. You don’t need medical billing for all procedure but if you avoid it fully it can result is lost revenue. If a review of your claim history can help to see opportunities for recovery and better reimbursement, it may be a good idea to reconsider medical billing.
Lastly, The Benefits of Medical Billing for Dental Practices
When it comes to medical billing for dental practices remember that it is not about adding complexity. It is about making sure that your practice gets paid appropriately for the care that you are already providing. If you have the right expertise and denial management process in place, medical billing can become a revenue opportunity for your practice instead of an operational burden.
For the practices that are experiencing recurring denials or that fully avoid medical billing due to complexity, Apex Claim Solutions can help you in evaluating your current process and identify areas for improvement.
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