Dental Cross-Coding billing and accounts receivable

Some dental procedures are payable by medical plans, and the practice that never bills them loses the revenue entirely. The work is knowing which ones, and proving medical necessity to a plan that does not think of itself as dental.

Where the money leaks in dental cross-coding

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• Medically necessary dental procedures billed only to the dental plan, or not at all
• Medical claim submitted without the diagnosis linking the procedure to a medical condition
• Surgical extractions and biopsies denied for missing pathology or imaging support
• Sleep apnoea appliances denied for coverage criteria the chart does not evidence
• Coordination between medical and dental benefits handled as if only one plan existed

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working dental cross-coding, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-50 — Not deemed medically necessary
  The payer does not accept that the documentation supports the service. This is a clinical argument, not a clerical one.
  Recovered by being appealed with clinical documentation. Matched from: “Sleep apnoea appliances denied for coverage criteria the chart does not evidence”
• CO-22 — May be covered by another payer
  The payer thinks somebody else is primary. Until coordination of benefits is corrected on their file, nothing on this claim will pay.
  Recovered by being fixed at coordination of benefits and rebilled. Matched from: “Sleep apnoea appliances denied for coverage criteria the chart does not evidence”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a dental cross-coding AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions