There is a very easy way to make dental insurance A/R look like it is being worked when it really isn't. Open the claim, check the status, put a note in the account and move on to the next one. Technically, something happened. Unfortunately, the practice still doesn't have its money. Tracking dental insurance claims is not about proving that somebody looked at them.
The purpose is to identify claims that have been delayed, rejected, denied, are waiting for additional information or were never properly submitted in the first place, and then do whatever is required to move them toward resolution. That distinction matters because a surprising amount of insurance follow-up can become activity without accomplishment if nobody is paying attention to what the status actually means.
Once treatment has been completed and a claim has been submitted, the practice has money sitting outside the practice waiting to come back. Some claims will process normally and some won't. The financial coordinator's responsibility is to know the difference. That requires more than occasionally looking at an aging report when collections are down and everyone suddenly becomes interested in where the money went.
Claim tracking should be a routine system. Insurance aging should be reviewed regularly, outstanding claims should be identified and problems should be handled while there is still plenty of time to correct them. The goal is very simple: claims do not get to disappear into the wonderful land of "pending" and live there indefinitely.
Your insurance aging report is a worklist, not a decoration
Most dental practice management systems can produce some version of an insurance aging or outstanding claims report. The name varies depending on the software, but the purpose doesn't. The report should identify claims that have been submitted but have not been paid, how long they have been outstanding and the information necessary to investigate them. That makes the insurance aging report one of the most useful tools in the financial area because it shows you where unpaid insurance money is sitting.
What it doesn't automatically tell you is why the money is still sitting there, and that is where the actual work begins.
The older a claim becomes, the more attention it deserves. A claim that has recently been submitted is not the same problem as a claim that has been sitting unpaid for months. The aging report should therefore be used to identify which claims require action and to make sure older claims don't simply continue moving from one aging category to the next while everybody assumes someone else is handling them.
There is a reason for paying attention to this early. A missing X-ray that wasn't sent when the payer requested it will still be missing several weeks later. An incorrect subscriber number does not eventually correct itself because everyone gave it enough privacy. Meanwhile, correction and appeal deadlines can continue to move closer.
This is also why I don't like waiting until claims are seriously old before anyone investigates them. Your claims should be submitted promptly. Most electronic claims are processed within about two to four weeks, depending on the payer. If an electronic claim has not resolved within the expected processing period, follow-up should begin. You want to discover the problem while there is plenty of time to fix it, not months later when the account has become part of the archaeological section of your A/R report.
Some "unpaid claims" were never claims at all
The aging report has one blind spot. It can only show you claims that exist. You cannot follow up on a claim that was never created. A completed procedure may never have been attached to a claim or submitted, and if nobody audits for that problem, the practice can spend a considerable amount of time wondering why insurance hasn't paid money the carrier was never asked to pay.
That is why an unbilled procedures audit belongs in the financial control system. The audit should identify completed procedures that aren't attached to claims, procedures incorrectly marked as not billable to insurance and claim-creation failures. There is an important distinction because some internal office procedure codes genuinely are not meant to be billed to insurance. If those repeatedly appear on the report, fix the settings so the report isn't cluttered with things nobody should be chasing. The purpose of an audit is to find actual problems, not create another report for somebody to admire.
Imagine a procedure was completed two months ago. The patient account shows a balance, the practice is waiting for insurance money and everyone assumes the carrier is slow. Except the carrier isn't slow. The carrier has no idea any of this happened because nobody submitted the claim. You can check the payer portal every Tuesday until Christmas and it will remain impressively unable to process something it never received. Before deciding the insurance company is failing to pay you, make sure you actually billed them.
Dental insurance claim tracking requires more than an aging report
The aging report tells you which claims need attention. The payer portal can help tell you what is actually happening with them, so both should be used. Once you locate the claim using the available patient, date-of-service or claim information, you may be able to see when the payer received it, its current status, a pending reason, denial information, requests for additional documentation and payment information.
That information is useful because now you have something much more valuable than "this claim is 37 days old." You have an indication of why it is 37 days old and what may need to happen next.
This is where dental insurance follow-up should become very specific. "Checked portal" is not a useful result by itself because the purpose of checking the portal was to learn something. If the claim shows submitted or received, you know the payer has it in the system. If it shows pending or in process, you know it is under review, but you still need to pay attention to how long it has been there and whether the payer is waiting for something.
If it shows approved, payment needs to be monitored until it is actually received. If it shows denied, the denial needs to be understood and handled appropriately. If the payer is requesting additional information, somebody needs to obtain that information and send it. The status is supposed to determine the next action; otherwise, checking the status accomplished very little.
"Pending" is a status, not a retirement plan
Pending claims deserve particular attention because the word itself sounds reassuring. Nothing has technically gone wrong yet. The claim isn't denied. The payer has it. Everyone can relax. Unfortunately, that isn't necessarily true. If the claim has been pending longer than expected, the next step is to find out why. The portal may contain a note explaining the delay or requesting documentation.
There may be a submission problem that needs to be corrected. There may be some other issue preventing processing. Whatever the reason, the useful question is not whether the claim still says pending. The useful question is what is preventing it from moving.
There are also times when a phone call is still necessary even when the practice has portal access. If a claim has remained pending without a clear explanation, a denial reason is unclear or contradictory, payment supposedly went out but the practice hasn't received it, or the payer says attachments weren't received even though they were sent, direct follow-up may be required.
Before making the call, have the patient and subscriber information, dates of service, claim information and CDT codes available. There is little point in spending your time getting through to the payer and then discovering you don't have the information required to discuss the claim. Insurance follow-up already takes enough time. We don't need to make it recreational.
Additional information requested means somebody needs to do something
One of the easiest ways for a claim to age unnecessarily is for a request for information to be treated as though it were merely an interesting update. The payer wants an X-ray, narrative, periodontal charting or clarification of something submitted with the claim. That request is now the next action. Gather the documentation and send it using the appropriate method, then document what was sent, when it was sent and any confirmation or reference information available.
That documentation matters because "we sent it" and "the payer received it" are not always the same thing. If the claim remains unresolved later, the person working it needs to know what happened previously so they aren't starting from scratch every time the account appears on the aging report. Good account notes should create continuity. The next person reviewing the claim should be able to understand the problem, see what has already been done and determine what happens next.
Otherwise, you get the insurance version of Groundhog Day. Someone opens the claim, discovers that the payer needs an X-ray and makes a note that the payer needs an X-ray. A week later, somebody else opens the claim and makes the fascinating discovery that the payer still needs an X-ray. Another note is added. Everyone has technically worked the account twice and the claim is still sitting there unpaid. At some point, we should probably send the X-ray.
A denied claim is not a completed claim
A denial is a decision from the payer, but it does not automatically mean the practice's job is finished. The first responsibility is to determine why the claim was denied. Claims can be denied because of missing information, incorrect subscriber data, coding errors, missing narratives or X-rays, eligibility issues, waiting periods or coverage limitations. Once the reason is known, the appropriate next action can be determined. Some claims need correction and resubmission. Others may require an appeal with supporting documentation.
The timing matters because insurance plans can have deadlines for corrected claims and appeals. If a legitimate claim is denied because something was missing or incorrect, there may still be an opportunity to get it paid. That opportunity becomes considerably less useful if nobody discovers the problem until the applicable deadline has passed. This is one of the reasons old insurance A/R bothers me. It isn't simply unattractive on a report. It can represent money that is becoming harder to recover because nobody acted when the problem could still be corrected.
This is also where responsibility becomes very useful. The insurance company is responsible for what the insurance company does. If the payer incorrectly processes a properly submitted claim, the practice needs to follow up and get the issue addressed. But sometimes the practice made the mistake. If the subscriber information was entered incorrectly, the required documentation wasn't sent or the claim wasn't submitted correctly, being annoyed with the insurance company isn't particularly productive.
Fix the problem. Responsibility is not about deciding who deserves to be blamed. It is about identifying what is preventing payment and getting the appropriate person to handle it.
Approved doesn't mean the job is finished
There is another place where claim tracking can stop too early. The portal says approved, everyone celebrates quietly and the claim disappears from active attention. But approval is not the final financial result. Once the claim is approved, the payment amount should be confirmed and the EFT or check monitored. When the EOB and payment are received, the payment needs to be posted correctly and the patient's account needs to reflect the actual insurance payment and remaining legitimate patient responsibility.
This may sound painfully obvious, but financial systems tend to develop little stopping points where people unconsciously decide their part is finished. The person filing claims believes the job ended when the claim went out. The person doing follow-up believes the job ended when the payer approved it. The person posting payments assumes whatever arrived must be right. Meanwhile, the owner assumes somebody is watching the entire process.
Somebody has to watch the entire process because the final result is not a favorable status on a payer portal. The final result is that the appropriate payment was received, posted accurately and the account correctly reflects what occurred.
Thirty, sixty and ninety days should mean something
I don't believe in staring at aging categories simply because the software thoughtfully divided them into columns. The categories should change what happens to the account. Claims that have moved beyond the normal processing period should be investigated. As they age further, follow-up should become more urgent and better documented. Once claims become seriously old, management should know about the problem rather than discovering it months later when the practice suddenly needs cash and somebody finally looks closely at the aging report.
If the same claim simply moves from one column to the next while receiving essentially the same note every few weeks, you aren't really using an aging system. You're watching the claim get older. There should be progression. Perhaps the first investigation shows the payer needs documentation, so you send it. The next review confirms receipt. If the claim remains pending beyond the appropriate period, you follow up.
If it is denied, you determine why. If a correction is required, you correct it. If an appeal is appropriate, you handle it within the applicable deadline. Every time the claim is touched, the person working it should be able to answer one question: what needs to happen next to get this resolved? That is considerably more useful than asking whether somebody "worked the account," because people can work accounts all day long. What matters is whether the work is moving those accounts toward resolution.
What dental insurance billing services should be doing with your claims
When a practice evaluates dental insurance billing services, I would look beyond whether the company says it "does follow-up." Almost everybody can put that phrase on a service page. Find out what follow-up actually means. Are outstanding claims identified systematically through insurance aging? How frequently are unresolved claims reviewed? What happens as they become older? Are payer portals used to determine the actual status?
Are documentation requests handled? Are denials moved into correction or appeal when appropriate? Is follow-up documented so the next person knows what happened? Are approved claims followed through to actual payment? Is anyone checking for completed procedures that never became claims? Those questions tell you considerably more than the phrase "insurance follow-up."
The same standard applies if you keep the function in-house. Being busy is not the measurement. Number of calls isn't the measurement. Number of accounts touched isn't the measurement. The condition of the insurance A/R is a much better measurement because claims should be moving, problems should be identified, required actions should be completed and old balances should not be quietly accumulating while everyone is very busy working the report.
This is also where a dental billing company or an internal financial coordinator has to understand the difference between activity and responsibility. A beautiful list of actions can make everyone feel productive. Claims submitted, portals checked, calls made, notes entered and reports run can all look impressive. Now look at the insurance A/R. If the old money continues to grow, the activities are not producing the result they are supposed to produce.
Dental insurance billing is full of details, and there is no way around that. But the basic responsibility is not complicated. Once a claim leaves the practice, somebody needs to keep track of it until the financial result is known and the account is resolved. If something is missing, get it. If something is wrong, correct it. If the payer needs to act, follow up.
If the claim was denied, find out why. If it was approved, make sure the money actually arrives and is posted correctly. If the claim never went out in the first place, fix that too.
Checking the status is useful because it tells you where the claim is and what is happening with it. The mistake is confusing that information with the finished job. The practice did not perform dentistry so somebody could become extremely proficient at reading the word "pending" on a payer portal. It performed dentistry to treat the patient, and the financial side of the practice is responsible for collecting the money legitimately due for that treatment. Claim tracking is one of the systems that makes sure that actually happens.
A lot of what you produce doesn't become money until an insurance company says so. That's not a part of your practice to leave to whoever has a spare minute. Book a consult
