The Dental Billing Podcast

Episode 86: Are You Giving Insurers Permission to Deny Your Claims?

• Ericka Aguilar • Season 11 • Episode 6

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Insurance companies are using AI to evaluate dental x-rays, denying claims when specific landmarks aren't visible in the images. This shift means approximately 70% of claims are now processed through artificial intelligence systems that disqualify submissions based on technical deficiencies rather than subjective human review.

• Poor quality x-rays with cone cuts or missing apexes give insurance companies legitimate reasons to deny payment
• Clinical teams need training to understand what qualifying x-rays look like for different procedures
• Billing starts with proper clinical documentation and supporting attachments, not in the billing department
• Digital x-rays allow immediate quality assessment - retake poor images immediately
• Even the best billers can't overcome insufficient evidence when appealing denials
• Creating a list of procedures requiring x-rays and examples of qualifying images can help train staff
• When benefits are available and evidence is sufficient, insurance companies should pay claims
• Proper documentation creates leverage when fighting unreasonable claim denials

If you need help training your clinical teams on how to improve x-ray quality for insurance submissions, I have a step-by-step process available. Send me a message to discuss what's happening in your office.


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Speaker 1:

I was woken up this morning to a text message from one of my billers and it was an x-ray a PA for a crown seating. I have talked about this in the past and I've talked about how dental insurance companies are using artificial intelligence. If you go back to I believe it's a couple episodes previously and I talk about AI and claims and the new era of dental billing. These insurance companies have indicated the landmarks that are required for x-rays in order to qualify for payment. It's no longer, for the most part, a human subjectively looking at an x-ray and using a little bit of you know, a little piece of this part of the x-ray and going, okay, this seems to be okay. Ai will flat out deny your x-rays if the proper landmarks are not represented for the requirements that it is taught to look for. So this x-ray was for a crown seat and it had no apex. The coronal portion of the x-ray was cone cut. It was just not something that represents dental necessity or not dental necessity, because we're not trying to prove dental necessity in this x-ray, we're just trying to show that there's no open margins at seat. Either way, it wasn't a good x-ray and if this claim gets denied, we have no fighting chance to appeal. Yes, we could bring the patient back, but just think about the rework involved in trying to get this crown paid when we could just take the time to train our clinical teams to understand what our x-rays need to look like in order to get paid.

Speaker 1:

Because sometimes it's not the billers that are getting the denials, it's they have all they need or all you provide on the clinical side and that's all they have to go with. So sometimes the denial problem that a practice faces is because the clinical team is not taking the time to understand what we need to get paid. And if you have been a longtime listener, you know that I always say billing starts in the back. It starts with clinical documentation and then supporting attachments. Right, Because our job as billers is to package this claim in a way that the insurance company can't refute the fact that, A benefits are available and, B we provide sufficient evidence proving dental necessity.

Speaker 1:

This is not the first time I've received an x-ray from one of my billers because it's so bad they had to share it. We see this type of subpar x-rays all the time and we do our best to educate the practice and let them know either this x-ray wasn't sufficient or it's too old. That's another thing that we see. Nobody's taking the time to go through the account, or the chart, if you will, to determine if this patient has a recent x-ray to support what we're going to be doing today, Because if we're going based on x-rays that are two years old and I've seen this then that's a whole other issue.

Speaker 1:

We have to stay on top of whether or not we have the right x-ray. Is it recent? Do we have any cone cuts? Is it elongated? In other words, are there any reasons? Are we giving the insurance company a reason to deny this claim?

Speaker 1:

And I don't want to always make the insurance companies out to be the bad guys, because I do see a lot of chatter, myself included where we talk about how insurance companies look for reasons to deny claims. I'm going to flip that around and I'm going to say today sometimes we give the insurance company every right to deny that claim because we didn't take the time to make sure that we packaged that claim so well that they didn't have a fighting chance, but rather we submitted an x-ray with a cone cut, the apex was cut off and all of these things AI has been taught to disqualify for payment. So maybe your denial problem is not billing, Maybe the denial problem is on the clinical side, and I see this all the time. So this is your reminder to button that up, because AI is here and about 70% of your claims are being processed through AI. Ai is not subjective. It is only going to qualify or disqualify based on the landmarks that it was taught to identify for each procedure. So now that we know this, we have to do better on the clinical side so that our claims are so strong that AI qualifies and pushes them on through for payment.

Speaker 1:

Because for payment? Because AI is first going to make sure that all of the things it was taught to identify in your x-rays qualify. Then it will move on to everything else, but it is going to start with your x-rays. So this is your reminder to double check x-rays before they are sent out, because we are going to see an uptick in denials, not because insurance is trying to save money, not because insurance is trying to deny your claim, Not because insurance is trying to deny your claim, but solely based on the fact that we are giving them every right to deny that claim with poor x-rays. So, with that being said. This is just a quick reminder.

Speaker 1:

If you need to train your back office and show them what qualifying x-rays look like, I would suggest you do so. I would write down all of the procedures that require x-rays as attachments and I would show your back office what those x-rays need to look like so that there's no excuse Nobody can say I didn't know. Everybody that takes x-rays knows what a good x-ray looks like and a bad x-ray looks like. If it's a bad x-ray, retake it looks like. If it's a bad x-ray, retake it. Take the time to retake it.

Speaker 1:

Most of us are using digital x-rays. You see the result instantly. It blows my mind when I see cone cuts. I see elongated anteriors or upper anteriors, lower anteriors. I see blurry fight wings. We have to do better. They are taught to look for good x-rays. Make a list of all of the procedures that need x-rays. Show your team what those x-rays need to look like and hold the team accountable to quality x-rays so that we have a better fighting chance in getting paid.

Speaker 1:

This is not going to guarantee payment. This is going to increase our ability to prove dental necessity when the benefits are available to the patient, because that's what we do as billers, we are proving to the insurance company that this procedure was necessary and here is the supporting evidence providing dental necessity. That's it, because at the end of the day, when the benefits are available to the patient and we provide sufficient evidence, the insurance company needs to pay that claim. You guys know how adamant I get about denials when benefits are available to the patient and you look at how you package the claim and it's a solid package. X-rays are on point, clinical notes have been attached and clinical notes are on point. All the things that we need to get paid are present and they still denied the claim. We don't tolerate that.

Speaker 1:

So, with that being said, friends, I just wanted to make sure that I gave you a reminder. Please do better with your x-rays. You give us a fighting chance as billers to appeal to prove that the insurance company is being unreasonable it's called unreasonably denying the claim when or if we ever have to approach the insurance commissioner to get the insurance commissioner on board so that we can stop this pattern. But that can only happen if we internally in the office are providing sufficient evidence to prove dental necessity with qualifying x-rays. Okay, I think I've made my point and if you guys have any questions about how I train clinical teams, on how to improve.

Speaker 1:

I do have a step-by-step process. Feel free to send me a message, talk to me about what's going on in your office. And again, if you don't give us quality x-rays, you leave us with insufficient evidence to prove dental necessity, even when the insurance company is unreasonably denying. We have no fighting chance as billers and I cannot advocate for the patient and their benefits. Help me, help you, help us help our patients, so that we can ensure our patients are receiving the benefits that they pay for every single month. All right, friends, I hope everybody is having a great Thursday morning. I will see you in the next episode.

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Ericka Aguilar

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