Our Services

Adjustment and Adjudication Services for Dental Practices

Managing adjustments and adjudications is a crucial part of the revenue cycle for dental practices, ensuring that you are paid accurately and promptly for the services rendered. Adjustments are typically made when there are discrepancies between what was billed and what the insurance company or patient is responsible for paying. Adjudication, on the other hand, is the process of reviewing, analyzing, and deciding how claims will be paid, which often involves assessing the validity of claims, coding accuracy, and compliance with payer policies.

At ExpertsRCM, we provide expert Adjustment and Adjudication Services to help your dental practice navigate these complex and often time-consuming processes. Our team of billing professionals works diligently to resolve discrepancies, process adjustments, and ensure that claims are adjudicated correctly, so your practice can maximize revenue and minimize denials or underpayments.

Why Adjustment and Adjudication Services are Important:

Effective adjustment and adjudication services are essential for several reasons:

• Minimizing Revenue Loss: Adjustments and adjudications ensure that your practice receives the full payment it is entitled to, whether it’s from an insurance company or the patient.
• Ensuring Billing Accuracy: Without the correct adjustments or adjudication of claims, your practice may face discrepancies in payment amounts or be forced to write off balances that could have been collected.
• Reducing Denials and Rejections: Proper adjudication helps prevent denials, rejections, or underpayments, which can significantly delay the payment process and impact cash flow.
• Enhancing Compliance: Navigating insurance policies and payer-specific guidelines correctly helps your practice stay compliant with regulations and avoid compliance issues or audits.

Our Adjustment and Adjudication Services:

At ExpertsRCM, we offer comprehensive Adjustment and Adjudication Services that aim to optimize your revenue cycle by resolving discrepancies in claims, ensuring proper payment, and keeping your practice’s finances in order. Here’s how we handle these processes:

• Minimizing Revenue Loss: Adjustments and adjudications ensure that your practice receives the full payment it is entitled to, whether it’s from an insurance company or the patient.
• Ensuring Billing Accuracy: Without the correct adjustments or adjudication of claims, your practice may face discrepancies in payment amounts or be forced to write off balances that could have been collected.
• Reducing Denials and Rejections: Proper adjudication helps prevent denials, rejections, or underpayments, which can significantly delay the payment process and impact cash flow.
• Enhancing Compliance: Navigating insurance policies and payer-specific guidelines correctly helps your practice stay compliant with regulations and avoid compliance issues or audits.

Our Adjustment and Adjudication Services:

At ExpertsRCM, we offer comprehensive Adjustment and Adjudication Services that aim to optimize your revenue cycle by resolving discrepancies in claims, ensuring proper payment, and keeping your practice’s finances in order. Here’s how we handle these processes:

• 1. Adjustment Management:

  Adjustments are typically made when there is a difference between the amount billed and the amount paid by the insurance company or patient. This discrepancy could result from a variety of factors, such as:

  • Underpayments: Insurance companies pay less than the billed amount, requiring adjustments to reflect the correct amount due.
  • Overpayments: The payer may have paid too much, necessitating an adjustment or a refund.
  • Contractual Allowances: Insurance companies often pay based on pre-agreed contract rates, which may be lower than the billed amount.
  • Write-offs: Sometimes, adjustments are made to account for amounts that are not collectable, including balances that are the responsibility of the patient but remain unpaid.

  Our team handles adjustments in a timely and accurate manner to ensure your accounts are updated and your practice receives the correct reimbursement. This includes:

  • Identifying Underpayments and Overpayments: We analyze EOBs/ERAs to identify discrepancies between the amount paid and the amount expected, ensuring that all discrepancies are addressed.
  • Ensuring Contractual Compliance: We review payer contracts and ensure that payments align with the terms agreed upon between your practice and the insurance provider.
  • Adjusting for Denied or Disallowed Claims: If an insurance provider denies or disallows a claim for any reason, we handle the necessary adjustments to ensure that the correct amount is billed or written off accordingly.
• 2. Claims Adjudication:

  Claims adjudication is the process of reviewing a claim submitted to the insurance company to determine how much will be paid and whether the claim is valid. The adjudication process may involve:

  • Eligibility Verification: Ensuring that the patient is eligible for the services provided.
  • Code Review: Ensuring that all medical codes (CPT, ICD, CDT) and diagnoses are accurately listed and match the services rendered.
  • Claims Scrubbing: A review process to ensure the claim is complete and meets payer requirements before submission. This helps prevent rejections or denials due to incomplete or incorrect information.
  • Payment Determination: The insurance company assesses the claim, and the adjudicator will determine the amount of coverage, co-pays, deductibles, and any patient responsibility.
  • Appeal Process: If the claim is denied or underpaid, the adjudicator evaluates the reasons for denial and prepares necessary appeals or adjustments.

  We manage the entire adjudication process to ensure claims are processed efficiently and correctly, ensuring that your practice receives the maximum reimbursement possible. This includes:

  • Claim Review: We check the claim details for completeness, accuracy, and adherence to payer guidelines.
  • Payer Communication: If additional documentation is required or if a claim needs to be resubmitted, we directly communicate with the payer to resolve issues.
  • Adjudication Tracking: We monitor the progress of claims through the adjudication process and follow up on outstanding claims, reducing delays and improving payment timelines.
• 3. Handling Denials and Discrepancies:

  Claims denials or discrepancies are inevitable, but handling them promptly and correctly is essential for recovering revenue. Our team specializes in:

  • Analyzing Denial Reasons: We carefully review the reason codes provided by payers to understand why a claim was denied and determine whether the issue can be resolved through an appeal or resubmission.
  • Appealing Denied Claims: We submit timely and comprehensive appeals to contest incorrect denials or underpayments, ensuring that all required documentation and coding adjustments are made.
  • Corrective Actions: If the denial is due to a coding error or missing information, we quickly correct the issue and resubmit the claim to the payer.
• 4. Coordination of Benefits:

  When patients have multiple insurance plans (e.g., primary and secondary insurance), the adjudication process can become more complex. We manage coordination of benefits (COB) to ensure that all insurers are billed correctly and that payment is received from the appropriate insurer based on the patient’s coverage:

  • Primary vs. Secondary Coverage: We ensure that the primary insurance pays first and that secondary insurance is billed for any remaining balance.
  • Maximizing Reimbursement: We help coordinate claims to ensure that all available benefits are used, maximizing your reimbursement and reducing patient balance.
• 5. Customized Reporting:

  We provide detailed reports on all adjustments and adjudication activities to keep you informed about your practice's financial status. These reports include:

  • Aged Accounts Reports: Insights into accounts with pending adjustments or unpaid claims, categorized by aging (30, 60, 90 days, etc.).
  • Adjustment Tracking: Reports on the adjustments made (underpayments, overpayments, write-offs) and the reasons behind them.
  • Denial and Appeal Statistics: Data on claim denials, the reasons for denials, and the success rate of appeals.
  • Payment Trends: Tracking payer behavior, including payment timelines, reimbursement rates, and any payment delays or issues.

Key Benefits of Our Adjustment and Adjudication Services:

• Improved Revenue Recovery: Our expert team ensures that all necessary adjustments are made, maximizing your reimbursements and minimizing write-offs.
• Faster Payment Resolution: We expedite the adjudication process by ensuring claims are accurately reviewed, reducing delays in payment and improving cash flow.
• Minimized Claim Denials: Through proactive denial management, we help reduce the number of claims that are denied, and we work to ensure denials are resolved quickly and effectively.
• Enhanced Compliance: We stay on top of payer-specific policies and regulations to ensure your practice remains compliant with all applicable billing and coding rules.
• Data-Driven Insights: Our comprehensive reporting and analytics help you make informed decisions about your practice’s revenue cycle and identify areas for improvement.

Why Choose ExpertsRCM for Adjustment and Adjudication Services?

At ExpertsRCM, we specialize in optimizing your dental practice's revenue cycle by handling the intricacies of adjustment management and claims adjudication. With our experienced team of professionals, attention to detail, and dedication to maximizing your revenue, we ensure that your practice gets paid for the care you provide.

By outsourcing your adjustment and adjudication processes to ExpertsRCM, you can free up valuable time and resources to focus on patient care while we handle the complexities of payer communications, denials, and claim resolutions.