Insurance claim denied. Office receives notice.
80% of practices do not appeal. The denial becomes aged AR. Money is written off.
But 40-60% of denials can be successfully appealed and recovered.
Why Denials Happen
Coding error: Procedure code submitted incorrectly
Missing information: Pre-authorization missing or not submitted
Patient eligibility: Insurance checked, but eligibility was outdated
Medical necessity: Insurance questions if procedure is necessary (rare but happens)
The Typical Denial Workflow (Broken)
Claim is denied. Notice arrives.
Billing staff receives notice. Feels overwhelmed. Does not know how to appeal.
Notice is filed. Weeks pass. Patient has not heard from practice.
Patient calls: “Why wasn’t my claim paid? I thought your office was handling it.”
Office struggles to respond. Staff do not know claim status. Weeks more pass.
Patient is upset. Office loses relationship.
Claim is never appealed. AR ages. Written off as loss.
Total loss: $300-1,500 per denied claim.
The Solution: Dedicated Denial Management
Reach team member manages all insurance denials.
Workflow:
Claim denied. Notice arrives at practice.
Reach team member receives notice immediately. Categorizes denial reason:
- Coding error (resubmit with correct code)
- Missing pre-auth (obtain pre-auth, resubmit)
- Patient eligibility issue (verify coverage, resubmit)
- Medical necessity (request peer-to-peer review with dentist and insurance doctor)
Reach team member takes action:
- Simple denials: Corrected and resubmitted within 3 days
- Complex denials: Reaches out to insurance. Requests appeal consideration. Documents appeal response.
Within 30 days, appeal decision is received. If approved, claim is resubmitted. If denied, Reach team member requests written explanation and patient is informed.
The Results
Denial appeal rate: Increased from 20% to 95%+ (75-point improvement)
Denial recovery rate: 50-60% of appeals are successful
Recovered revenue: On 20 denials monthly, 2-3 were previously appealed (success rate 30%). Now, 18-19 are appealed (success rate 50-60%) = 9-11 recovered instead of 1-2.
Additional recovered revenue: $2,700-4,500 monthly
Cost: One remote team member managing denials: $1,200 monthly
Net benefit: $1,500-3,300 monthly in recovered denied claim revenue
Why Most Practices Fail at Appeals
Appeals require persistence. Multiple follow-up calls needed.
Appeals require documentation. Correct codes, medical records, peer-to-peer letters.
Appeals require time. Staff are too busy with daily work.
Dedicated person solves all three problems.
Implementation
Step 1: All denied claims are logged into a tracking system
Step 2: Reach team member reviews daily
Step 3: Categorizes denial reason
Step 4: Takes appropriate appeal action
Step 5: Tracks appeal status and documents responses
FAQ
**Q: What percentage of denials are recoverable?**
A: 40-60% can be recovered through successful appeals.
**Q: How long does an appeal take?**
A: 15-45 days typically. Depends on insurance.
**Q: What if insurance continues to deny?**
A: After 2-3 appeal attempts, consider patient balance. May need to collect from patient.
**Q: Do I need to involve the dentist in appeals?**
A: Only for medical necessity denials. Peer-to-peer reviews may be needed.
**Q: Can I appeal after 90 days?**
A: Yes, appeals can be submitted up to 1 year in some cases. Check insurance plan details.