Automatic Rejection THE RISE OF AI-DRIVEN CLAIM DENIALS
Dental insurance companies have begun to introduce Artificial Intelligence (AI) into their adjudication process, which has led to a noticeable increase in claim denials. While AI promises to improve efficiency, this development has also introduced significant new challenges both for patients and dental providers. Here, we will examine why AI is denying so many claims. Stricter Adherence While human adjudicators are no doubt familiar with the contractual terms that govern their company’s insurance policies, AI adjudicators have a marked advantage in this area. Their algorithms meticulously analyze every aspect of a claim against the specific terms of the claimant’s dental insurance plan. This means that any minor discrepancy — such as a missing or incorrect procedure code — can trigger an automatic claim denial. Fraud Detection Thanks to the sophisticated underlying technology behind them, AI-powered systems are capable of identifying potential fraud; however, their sensitivity is overtuned, and this leads to numerous errors on their part. While this system may be beneficial for preventing fraudulent claims, it also leads to legitimate claims being flagged for further review, resulting in unnecessary delays and denials. Data-Driven Decision Making AI can analyze vast amounts of data to identify patterns and trends. This data- driven approach can lead to more stringent criteria for claim approval, particularly for procedures that are frequently challenged. The more efficient the AI becomes
in doing so, however, the more difficult it is for human adjudicators to keep up with the claim responses. That is to say, as the AI takes on more tasks, there is less opportunity for human review and intervention. This can limit the ability to consider individual circumstances or exceptions, leading to more rigid decision-making. The Takeaway Dental providers must invest more time and resources in appealing denied claims, which can be a complex and time-consuming process. Additionally, denials can delay or prevent payments to dental providers, impacting their cash flow and financial stability. While this affects dental providers, it also leads to hardships NEW CODE ALERT D6180 - Implant maintenance procedures when a full fixed arch hybrid prosthesis is not removed, including cleansing of prosthesis and abutments.
for patients. Patients may experience unexpected out-of-pocket costs and dissatisfaction with their dental provider. While AI has the potential to streamline the dental insurance claims process, it is important to be aware of its potential drawbacks. By understanding the reasons for increased denials and taking proactive steps to mitigate them, dental providers can minimize the negative impact on their practice and patient care. SHOTS FROM THE 2ND ANNUAL MOLAR CUP
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