The Dental Billing Podcast

The Power of Defensive Documentation and Avoiding Prison with Dr. Roy Shelburne

• Ericka Aguilar • Season 7 • Episode 1

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Do you ever wonder about the intricacies of insurance claims and the importance of having proper documentation in dental practices? We bet our guest today, Dr. Roy Shelburne, can shine a light on that. A seasoned dentist, practice owner, and survivor of a healthcare fraud conviction, Dr. Shelburne's story is striking, a true eye-opener for other dental professionals, as he shares his experiences and the lessons he learned.

Dr. Shelburne passionately dives into the world of healthcare fraud, defensive documentation, and the consequences of insufficient documentation. He emphasizes that everyone in the dental team should take responsibility, reflecting that there's no such thing as an innocent mistake in healthcare documentation. Together, we explore the complicated relationship between dental practices and insurance companies, discussing how insurance benefits can influence the care provided by dentists. To prevent falling into pitfalls, we underline the importance of understanding these benefits, accurate documentation, and the use of templates and drop-down boxes to support claims.

Wrapping up this riveting conversation, we delve into the critical role of proper documentation in a dental practice for more than just ensuring payment. We also discuss how to utilize templates and flexible records to accurately reflect a patient's condition, and diagnosis, and how to navigate insurance company guidelines. This episode is brimming with valuable lessons from Dr. Shelburne, who now uses his experience to guide others in the industry. Don't miss it!

Got questions for Dr. Shelburne? Connect with him @ www.royshelburne.com

Want to learn Dental Coding and Billing? Join here:

https://tr.ee/efzYrY7mp-

Would you like to set-up a billing consultation with Ericka or Jen? We would love the opportunity to discuss your billing questions!

Email Ericka:
ericka@dentalbillingdoneright.com

Email Jen:
jen@dentalbillingdoneright.com

Perio performance formula:

(D4341+D4342+D4346+D4355+D4910)/(D4341+D4342+D4346+D4355+D4910+D1110)


Want to know what your fee should be for D4346? Send Ericka an email to ericka@dentalbillingdoneright.com


Speaker 1:

Dr Roy Shelburne, thank you so much for being on the Dental Building podcast. I am so excited to have you here. We spoke a couple of weeks ago and we passed the idea of having you on the podcast and you went on a very long vacation which where was that to? Again?

Speaker 2:

I did Norway and the Baltic. That's right. It was wonderful.

Speaker 1:

Yes, so we kind of reconvened a couple months after that, and here we are.

Speaker 2:

And here we are.

Speaker 1:

I'm so excited for the listeners that have never heard of you. We have a lot of front office team members, new dentist, a lot of people starting their practice. Why don't you introduce yourself and let them know who you are and and what your mission in dentistry is?

Speaker 2:

Well. Thank you, erica. I appreciate the invitation. Always good to be able to speak with like minded individuals were billing coding documentation geeks, and I love that about you.

Speaker 2:

I am a dentist, husband, father, practice owner, now grandfather. Had a convicted felon. I went to prison for health care fraud, racketeering and money laundering. But I bet few of your listeners have heard a CV like that unless they've heard me introduced before. Practiced in the western part of Virginia for 27 years, flew to San Francisco, california, to the American Dental Association meeting and while I was there I learned that the FBI had come to my office. They battered down my boat by back door and were taking all my records. Was investigated for a period of three years, then indicted, then a year and a half later went to trial. Was found guilty of health care fraud, racketeering, money laundering and structuring. The jury's never made aware of the amount. It was a Medicaid issue.

Speaker 2:

I lived in a very small town in the western part of Virginia and about 90 to 95% of our individuals under 18 had Medicaid, so I had a busy Medicaid practice, felt it was important to take care of those individuals and they did the investigation over a period of six and a half years and over the six and a half years I was paid $3.5 million, which is a very active Medicaid practice and, as I said, the jury has never made aware of the amount. They only determine guilt or innocence. The government determines the amount that I got that I wasn't entitled to and did we make billing errors? We did the amount that I was paid $3.5 million the amount that the government established. Of the $3.5 million I got that I was entitled to, $17,899 and 57 cents, that's 0.01% of the amount that I build. And even though we were able to go over the same six year, six and a half year period and look over our billing and coding and we found that the amount of work that I actually had done could have built for, should have built for, but didn't to the tune of about $30,000 in that. So that made no difference. So, story is, the amount makes no difference.

Speaker 2:

And I guess, to segue to one of the things that we talked about in terms of responsibility, even though I didn't directly do the billing myself, somebody did it on my behalf I'm still held responsible for and there have been some actions in the near past that not only have they've named the doctor in the action, but also team members. So everybody has skin in the game and that's the thing that I want to share that we all have responsibility and we're all equally accountable in the event that there's an action taken. And, as I said in recent actions, I do name team members. So we have to be responsible for the actions that we have done in the game. It's all.

Speaker 2:

My goal, my passion, is to be the last dental professional goes to prison for things they didn't know or understand. So I share my story, not because I'm proud of it, I'm very ashamed of it, but I want to be the last professional who goes to prison for things they didn't know or understand. One of the things I didn't understand was the definition of intent to the fraud. I knew if you submitted a claim for a patient you never saw, for a service you never provided, legal definition of intent to the fraud is much broader. It includes what's called blind disregard, which means if you make similar errors and don't have systems to identify and correct those errors, that is considered blind disregard and intent to the fraud. So there's no such thing as an innocent mistake. So we'll be talking a little bit about that today so that, like I said, I share my story, not because I'm proud of it, but I want to help others to make sure that they don't make the same errors. That's my story and I'm sticking to it.

Speaker 1:

I love that. I love the topic of. You know there's no innocent mistakes and in your bio on your website you state that their ignorance is not a defense.

Speaker 2:

It is no case.

Speaker 1:

I have heard your story in the past and one of the things that I took away and this was probably 10 plus years ago when I first heard your story it was shared on a YouTube channel and it was a video. You have many videos on YouTube, so I do recommend everybody go check out those videos. Dr Shelburne is powerful and one of the things that you talked about was your documentation has to be able to defend you when you can't, and you talked about defensive documentation. I have a dental billing company so I do billing for offices. My team and I do billing for offices all over the country.

Speaker 1:

One of the things that we are very firm on with our clients is no billing without documentation. I don't care if the treatment is posted to the ledger or to the account. That is not okay to bill that because I don't know. I don't have any clinical documentation to compare what was posted, diagnosed and all of the things components that go along with compliance. So could you talk to us a little bit about the elements that are needed for defensive documentation and clinical documentation, what that should look like before you bill it?

Speaker 2:

Oh, absolutely. And when I, when I speak, I always ask the makeup of the audience, how many doctors, how many front desk, and I always ask through the course of the lecture, is how many of you always get all the information you need as billers to submit a claim and get it paid without delays or requests for additional information. And nobody holds up their hand because there's always that dropped ball where they don't have the information that they need. So they have to go fetch the doctor or the assistant or the hygienist to be able to give them that information. And if you want to arm your business people with everything, they need to be reimbursed. Number one make sure that you document accordingly, and documentation is not only going to get you paid. It will protect you because it will testify for you loudly and strongly in any action. And it's a way of elevating patient care so that you aren't called on to remember about this patient. It's all there in black and white, so you can move very directly from appointment A to appointment 13 and be able to look back. And there is a story that you can follow. You need to develop that story.

Speaker 2:

Before you treat anything in a patient's mouth, it needs to be preceded by a diagnosis. For example, I see a lot of practices doing active perioste systems in their practice and I almost never see a complete periodontal diagnosis which contains three variables it's either mild, moderate, severe, generalized, localized, chronic or acute periodontal disease or inflammation If it's gingivitis. And I see charting which would suggest there's periodontal issues and I see x-rays which would suggest as well. And I see treatment, but no diagnosis prior to. You can't treat before diagnosis. And you know I'm going to chase a rabbit here, eric. We talked about my ADHD, so this is one of those that I'm going to chase about.

Speaker 1:

I'm really going to be back right now, just so you know I'm really trying hard not to cut because I'm, like, so excited about this topic.

Speaker 2:

If my crystal ball works the way I think it's going to work we are going to move from dental billing using CDT codes to medical billing completely using ICD codes. And our medical colleagues, before they treat anything and before they're reimbursed, there needs to be a diagnosis prior to. In dentistry, we don't get the diagnosis means nothing. We get paid on what we do, which is backwards. You need to diagnose first and then put together a treatment based on the diagnosis which takes into consideration what we're treating and why we're treating it, so that it's paid. So you understand what you're treating. Anybody else who follows up can understand. You've diagnosed this and that's the reason why you're treating it and it's also moving us so that we're more capable of billing to medical. Okay, you had a question. I'm sorry.

Speaker 1:

We're going to be doing an event together here in a couple of months and I will survey the audience and I always ask the audience how many of you are using ICD 10 codes, and there will be zero hands that go up, or maybe one or two at the most. I agree with you. There are so many times, particularly with hygiene, when I am billing for SRPs or I see a bloody bid pro-fee documented and I'm not a dentist, I'm not a hygienist, but I know enough from the billing standpoint perhaps that could have been a gingival inflammation cleaning, and so I go and I look for the diagnosis and there is none, there's nothing. So what we documented, or what my hygienists document, are the bloody bid pro-fees. But particularly recently I just vented about this in a Facebook group and it was billing for SRPs and I had no peri-o chart on file, none. And I don't know how we could have properly diagnosed the patient with SRPs having periodontal disease, generalized chronic. I didn't even know which one it was.

Speaker 1:

So I didn't know which diagnosis code I could use to submit that claim. That just got me really fired up because I experienced that on a regular basis and that's why I try and emphasize to my clinical teams that billing really does start in the back, from the coding systems to the clinical documentation, and the reality is me, as a biller, I'm just packaging it so that it's a clean claim submission. But it starts in the back.

Speaker 2:

Well and to your point, couple of points. The ADA claim form was updated in 2012 to include what Diagnosis codes. You have boxes, you can add diagnosis codes. Were it something they would have done had that not been anticipated to be used? No, people don't do things unless they feel like they're gonna use them. So, yes, that indicates in there are now six states. If you see Medicaid patients, the diagnosis codes do need to accompany the claim and, for example, the 4346, it is scaling in the presence of moderate to severe generalized inflammation. Isn't the moderate to severe and generalized part of that diagnosis piece so that that should be contained within the documentation of that patient, so that that biller then is capable of billing that? Because unless that criterion is met in that clinical record, technically it's not billable. Because what supports the clinical submission? The documentation that's sent to the insurance company? Of course it's a clinical record. And worst case scenario let's talk about I'm a storyteller, we'll tell another scenario.

Speaker 1:

I love it.

Speaker 2:

So doctor diagnosed the need for a crown on tooth number 14. The person who's doing the billing opens the clinical record and, lo and behold, there's no justification for the crown there at all. It just indicates that the crown's necessary on tooth number 14. Biller needs to submit that to the insurance, either as a pre-D and we can go there if you want to or as a claim.

Speaker 1:

I have so much to say.

Speaker 2:

So the billing person finds the doctor and goes you've diagnosed a crown on tooth number 14 for Mrs Smith. Can you tell me what's going on there? As a doctor, you fire it off. Museo-facial cusp was fractured off the tooth was two thirds alloy marginal decay around the tooth. We need the crown to restore contour and function. The person is writing furiously and goes forward and enters all that information with the claim to the insurance carrier fired off. The insurance carrier paid without any delay because all the information's there.

Speaker 2:

But the person who listened to that scenario from the doctor was not trained or incapable of entering in that clinical record for the patient. So it's gone forever. And, for example, the doctor is audited by an insurance company and they pull this particular patient that we've talked about. They're chalked to review. They have a claim for tooth number 14 with all the documentation necessary to support that claim. They open the clinical record and there's nothing there to support it.

Speaker 2:

What happens to that reimbursement?

Speaker 2:

They ask for the money back and insurance companies in today's world can pull then 15 charts for patients who have had crowns delivered and they find that 15% of those charts have no documentation to support the need for the crown.

Speaker 2:

The insurance company uses that 15% and goes back over the course of seven years because the statute of limitation on fraud is seven years and asks for 15% back up all the crowns they've paid over that seven-year period. Doctors have written checks back for the insurance company for $350,000 because they have not documented appropriately. So is it important? Yes, some of them only care about the reimbursement. The documentation is something that goes ah, you know, that doesn't mean anything, we really don't need to do that, it only matters when it matters. So that would have saved this doctor. Had they had the person who had listened to the information been trained and capable of entering that information in the clinical record, then the doctor would have had the documentation there necessary to support the need for the crown and all would have been good. However, that simple training and the ability for that person to be able to enter that information was not followed through with.

Speaker 1:

So and to add to that, this is a leadership element. Added to that, that performance is tolerated. We're not following up on work with team members, and I know this because we have offices that are still going digital and they are using that method of just documenting, you know, writing it down, jotting it down, and then they will go, when they have time, go enter everything into the computer, if it ever gets done.

Speaker 2:

Who has? Who has that much time?

Speaker 1:

Nobody in today's, in today's employment landscape in dentistry, they're everybody short staff.

Speaker 2:

Absolutely.

Speaker 1:

We run the risk of missing these key points, these key elements to the process that could have you writing a check for 300,000. And I know I've been a part of those audits with the doctors who call in panic and say, erica, what do I do? I think I'm going to have to write this check for $84,000 back to etna, and etna is my number one insurance company in my office, and so what they're? If I can't write this check, they're just going to start deducting it from future payments.

Speaker 2:

Yes.

Speaker 1:

So you're going to pay it back.

Speaker 2:

Either way.

Speaker 1:

I love that point. So I think number one here is make sure that the clinical team knows how to enter the diagnosis, the treatment plan and all of those things that are important to defensive documentation. Is that what?

Speaker 2:

that would say Absolutely, absolutely. The same documentation that is going to get you paid will also protect you in the event of a malpractice claim. Yes, attorneys are just like everybody else. They look for the low hanging fruit and if they have a patient that complains about a doctor's treatments, the first thing that that attorney is going to ask for is a copy of the clinical record for that patient. And I can tell you, being very familiar with attorneys at this point they will look at the documentation and if it's bulletproof, if it defends what the doctor did and why they did it, or lack of compliance of the patient, whatever the situation is, they read that it's all documented, it's in black and white. That claim will never happen. That action will never happen.

Speaker 2:

The attorney is not going to swim upstream. It's too hard. You cannot punch holes in a clinical record that was established that way. However, if that record leaves wiggle room, if there's not complete documentation, if everything's not covered from A to Z, it leaves an opening that they can put a crowbar and pry the thing wide open. Those do move forward.

Speaker 2:

And thirdly, where I get involved more frequently than I care to is with helping doctors with their documentation CEs, and those generally happen when a patient's made a complaint to the board of dentistry and the cases that I've been involved with, the board has done an evaluation. They ask for everything copy of the doctor's clinical record and they review everything. Doctor's treatment met standard of care, no problem with what they did at all. But there was a problem with the documentation. It did not meet standards. So even though they provided appropriate care for the patient and that was a primary complaint because they did meet standard with their clinical record that brought action against their license as a result of their lack of proper documentation and I've had to remediate them to meet the state and or to meet the requirement that the board has established and that being the record that's always on their board record. So documentation is going to be so important and unfortunately dentists and teams feel like that's the least important thing in their day.

Speaker 1:

So I have a question for you what does proper documentation? We have a lot of doctors who have their assistance right, their clinical notes, and what they do at the end of the day is just review and sign off. If that happens, when you have an assistant documenting for you, what are your suggestions? Do you suggest a template Like what, how? How do you suggest we document?

Speaker 2:

Yeah. So I absolutely suggest that if you can defer anything that is is deferrable to a team member, absolutely do it. Doctors, your highest and best use is providing care for your patient and educated them. However, hear me, hear me very loudly do not ever do that until that team member that you're offloading that to is every bit as qualified and able to put together an adequate clinical record as you are. And you can do that with templates, absolutely.

Speaker 2:

I'm not a big proponent of having soup to nut templates. I am a big proponent of having different areas that need to be completed. And it's flexible, because if you pull in, for example, a hygiene record, and you pull in this huge block of hygiene record into the clinical record and you don't have the ability to modify that to reflect exactly what you see with that patient, they all look the same. And that was a suggest that all your patients are the same and are all our patients all the same? Absolutely not. So. So If you're able to for example, the periodontal diagnosis or the genital diagnosis I encourage you to do templates and add drop-down boxes so that the mild monitor is severe. You can open that, click on whatever it is generalize, localize, click, chronicle, acute click and you have that laid out. There are options that are available as far as you're restorative, those are easier to do if you use the same protocol with your post to your composites. Pull all that in, by all means, because you don't have to rewrite that every single time. But yeah, templates are great, but you need to have them flexible enough so that they are modifiable to very specifically address that patient's conditions and diagnosis as they present.

Speaker 2:

There again, the team member needs to be able to do that and the team member also needs to be able to listen and notate. For example, dr Watson sits down with the patient. Says Miss patient, I'm going to go ahead and do an oral cancer screening. I can guarantee you that 99.9 percent of all dentists do that routinely with their evaluations. However, I can also tell you that probably 90 percent of them never tell the patient what they're doing. The patient you sit down and go I'm going to do an oral cancer screening. The patient never heard this before. You've done it, but they didn't know what you were doing. They're going oh wow, this isn't just a checkup Getting oral cancer screening as well. That is going to add value to it. And your team member can listen.

Speaker 2:

Dr conducted oral cancer screening. As the doctor looks, he or she can go. There's this little red area on the roof of your mouth here. Can you tell me, have you ever noticed that? The patient can say, hmm, yeah, I think I burned that the other night on pizza. Doctor can say well, it looks like it would be consistent with a pizza burn. However, if you would take a look at that, I'm going to give you a mirror. This is what it looks like today. If in seven to 10 days, it's not gone, then please go ahead and give us a callback. We're going to need to take another look and maybe go a little bit deeper. Tim members listening to all that Doctor conducted oral cancer screening, noted an area, whatever that area is.

Speaker 2:

Instructed the patient. Patient indicated that they remember having a pizza burn in the area. Doctor indicated that it could be a pizza burn. But the patient is to call back in seven to 10 days and let him know what the condition is at that point. So all that's being listened to. The doctor doesn't have to say anything to the team member. The team member is trained to listen. Same thing with the TMJ evaluation. Patient opens and closed.

Speaker 2:

Mrs Smith, I can tell there's a little clicking and popping on the right hand side. Have you noticed that? Mrs Smith says yeah, I have noticed that. Does it ever hurt? No, no, I've had it for years. There's no big deal. So the person listening. So is there a learning curve? A little bit, but anybody can listen.

Speaker 2:

If you hear that they understand that need to capture this in the clinical record. Having that all determined, the patient or the team member knows the responsibility, what they should be listening for and noting in that clinical record, then it becomes organic. At the end of the day the doctor can review and sign that and one of the things that I don't see very often is the doctor signing the hygiene record. Hygienists can only practice independently now in three states and those hygienists need to have the certificate to be able to do that, otherwise they cannot diagnose. So anything that's noted there that they is their impression but we talked earlier about everything needs to be diagnosed before treated. That's where the periodontal diagnosis comes from. The hygienists can make a note of their impressions and what their thoughts it might be for the doctor to review and then put their stamp of approval on. So the doctor needs to review and sign those as well, unless that hygienist practices in one of those states that they can practice independently without the doctor.

Speaker 1:

So let me ask you, as an example, say, we have a patient that's coming in for a prophy and they're in the chair scheduled for the prophy, and the hygienist realizes this is a gingivitis cleaning. This is not a prophy.

Speaker 2:

Okay.

Speaker 1:

The suggestion there would be then go get the doctor, have the doctor review and diagnose, or what would your suggestion be in that case?

Speaker 2:

Yeah, if that were the case, I would Well. What makes it more convenient would be in an air practice Anytime. The hygienist has taken the necessary radiographs, done the necessary screenings, then the doctor's called. So there is a buffer in there, yes, so that the hygienist is going to have some time to maybe conduct some other do the periodontal probing, if that's the case, if there's so, there again the doctor needs to be awarded. But the doctor has to direct any type of treatment and, to be honest with you, simple thing is a prophy X-rays. The doctor has to order the need for radiographs based on number one medical necessity, not that the insurance is going to pay for it. I do audits.

Speaker 1:

Wow.

Speaker 2:

So the whole other Billing for benefit.

Speaker 1:

That's a whole other topic that you and I went off on. And our most busy conversation, friends, we talked about how Whiskey office is billing for the benefit, not for standard of care and for what it actually do Drive me crazy.

Speaker 2:

You will never meet standard of care. Billing for only about the insurance will allow. So chase this rabbit very, very shortly. X-rays are taken only because they're medically necessary, not because the insurance is going to pay for it. They need to meet standard of care. If you're billing for a radiograph that is comb cut, that is overlapped, that would not pass a proficiency in dental school, hygiene school, assisting school, you are billing for a worthless service. You've submitted a claim. It's a fraudulent claim because the X-ray is worthless.

Speaker 2:

And the third thing oh, my gosh, reach, reach, reach and the third thing that needs to be part of the clinical record regarding radiographs is that the doctor read them, because if it doesn't notate that the doctor read them, then it didn't happen. So you have X-rays that are taken and, according to your clinical record, they're just out there in space somewhere and never having been read. So, although we assume that the doctor read them, you can't assume anything that's not in the clinical record. So, yeah, there's so many different ways we can go from there, right?

Speaker 1:

Oh my gosh, In the clinical training that I have with assistance, because they are the ones gathering the attachments that we need in order to get paid to package a proper claim of the claims. So we do spend some time with the assistance. And I talk about this, friends, you guys. You guys know I've talked about this before. Comb cut elongation foreshortened, half the X-ray missing. We have to retake those X-rays.

Speaker 1:

So if you were digital you see it instantly you take the X-ray so that it meets standards and we don't. As a biller, I'm gonna speak billing language. As a biller, I don't wanna give the insurance company an excuse to deny or delay, and when we submit those X-rays we do give them a reason to.

Speaker 2:

And I'm gonna expand that even further, erica you could also give the insurance company an excuse to audit, because if they see a comb cut radiograph that was submitted to them as if it were standard of care and readable to justify the need for that. I had an office that did that did just that. The X-ray was not good. The person who reviewed that looked at it and went I wonder if they think this is standard of care if we do an audit of this practice of a radiograph. So I wonder what we're gonna find. And they did the audit and they found that 30% of the radiographs that we're taking in bill four did not meet the standard of care, were not diagnostic and they used the extrapolation formula I talked about. They asked for 30% back of all the radiographs they'd paid for over the course of that seven year period and that was $112,000 that Dr Rota checked for.

Speaker 2:

So I encourage the practices and I never about punishing anybody.

Speaker 2:

I'm all about identifying areas for improvement In your practice. You should have a code that you use that is not an ADA code that submitted the insurance, but it's a non-diagnostic radiograph so that anytime those are fired you make a notation that that's fired and that the diagnostic film. So once a month, once every six months, we're on a report and per assistant or per hygienist and just calculate their accuracy. So if you have one that is 90% accurate, only 10% retakes, and you have one that is 60% accurate, 40% retakes, that's an opportunity for that person to learn and grow. You get the one at 90% to do a little learn lunch and learn with the individual who is having, who's struggling. Because in most instances, say, a patient comes in, you're taking a PA first. Pa is taken and it's not great, and the assistant looks at that this is not gonna work and takes the second one and this probably doesn't happen with any of your people who listen to your podcasts because they're excellent at what they do but the second one's worse than the first.

Speaker 1:

Yeah.

Speaker 2:

Third, one's taken, it's perfect, and the doctor probably never is made aware of the two that don't meet standard. But who does know? Yeah, the patient. So they're thinking, oh my goodness, they have to take so many to get a good one. And your podcasts? People may not. I'm sure this doesn't happen with them either, but they have patients that refuse radiographs. Yes, that happens sometimes, oh my gosh. Two reasons one, they don't wanna pay for them and two, they don't want the exposure. And if you have patients who don't wanna have a full-mouth series taken because they're afraid of all the exposure, if they've had a couple of PAs and it's taken three or four times to take those films, and now you're gonna get 16 to 18, and multiply that by three because it's gonna take you three times to be able to get all those they're going, that's an awful lot of exposure. That might be one of the reasons why they're thinking I don't wanna be exposed to that many films Because you know, so there again, it's a way of tracing that and bringing everybody up.

Speaker 2:

You've got one person here at 90%, another person at 60%. You want all of them at 95 to 100%. Well, you can be 100, you can't be perfect because patients are a little bit difficult sometimes to get those films on oh yes.

Speaker 2:

But, like I said, it's the systems like that to implement in your practice to make sure that you get what you expect, not what you accept. And that happens in all dental practices and families, your children. You don't get what you expect, you get what you accept. So if the levels here you've established your level for your documentation everybody needs to meet the standard and you don't accept that, then you tend to start coming off from what your expectations are. So there again to have that system for documentation or any system in your practice. Make sure you're clear on your expectations. People are made aware of those expectations and they understand the repercussions if they're not able to meet those standards.

Speaker 1:

Yes, absolutely. And I think, kind of jumping into a different topic, because this is one of my favorite topics, especially when I'm talking to a live audience. I love to see the reactions and the aha moments when we talk about billing to benefit, not to standard of care or not for what you actually did, right? The next example of that is when we have a patient on a periomaintenance regimen and they bill pro-fee one visit, periomaintenance another, and when you ask them why they do that and they say, well, because on the off visit they will only pay for a pro-fee. And so I see your face. So we're just kind of like you don't bill for the benefit, bill for what you actually do. What are some other examples that you see offices billing for benefit not? I have a list in my head but I would love to hear your.

Speaker 2:

Oh goodness, radiographs is number one. Evaluations, oh pro-fee. Periomaintenance, oh goodness.

Speaker 1:

Crowns.

Speaker 2:

I mean, you know, crowns core buildups, restorations, you know you name it. It's kind of like we're gonna do it this way because this is what the insurance is gonna pay for. It's like mm. That's not even right. And you know a lot of them get all twisted because the insurance company has the least expensive alternative benefit.

Speaker 1:

Yes, the leasing costs.

Speaker 2:

Yeah, exactly. So you know. There again, there are such things as optional services and most insurance companies are aware of and allow you to do that. The insurance company cannot dictate to you. For example, the person comes in, they're missing tooth number 19. And the patient has the least expensive alternative benefit clause in their insurance. And the patient wants an implant and crown. So the insurance says all I'm gonna pay for is the partial. But if the patient wants to have the implant and crown, that in most cases is considered a optional service by the insurance carrier and you can balance the difference between those.

Speaker 2:

And most people don't know that and you know they think well, you know, I can't afford to do that because they're only gonna pay this. You know it's not a trick, it's something the insurance company's aware of and they cannot get between you and the patient. When there's decision, care decisions being made, they have a benefit. They're gonna pay this. It's gonna limit to that. But if the patient wants an upgrade to something different, then by all means you can do that. That's the patient's choice. But yeah, you know there are all kinds of things like that. People feel like they're limited and they are billing per benefit. Well, I guess we'll just have to give you a partial no, no please don't yes.

Speaker 1:

alternative benefits is exactly what I talk about when I'm making newer billers aware that we don't balance bill the patient to the benefit you can balance, bill the patient to the treatment that we actually did, or you know, for that matter, we can. Doctors can do what they feel is standard of care for the patient, but the insurance benefit doesn't matter. That's just what they're gonna pay for.

Speaker 2:

Exactly exactly. Preach on.

Speaker 1:

Yes, yes.

Speaker 2:

The insurance company cannot get between the doctor-patient relationship and the recommendation with that treatment plan that's appropriate for the patient. Insurance can only say this is what we're gonna pay for. They cannot say this is all you can get for this, it's no, it just drives me crazy. It's like don't do that. Patients deserve better.

Speaker 1:

Exactly, and I think it's just a matter of a lot of our front office team members just not knowing what they don't know, and that's why I was so excited to have you here today, because we're exposing them to things that I don't think a lot of times they get that too. They get that exposure for. So can you talk to us about what you do when you work with an office? What is it that you're looking for? What are you doing when you're helping your clients?

Speaker 2:

So, ultimately, I want to help them maximize legitimate reimbursement, reduce the risk. I wanna keep them out of harm's way and get paid for everything they're entitled to, and I'll help them squeeze every penny out of that insurance company that they're entitled to. No more, no less.

Speaker 1:

Yes.

Speaker 2:

So can you squeeze blood out of a turntable? Turn it. Yes, you can. You teach them about the magic words that go along with the billing that you know? I jokingly asked individuals when they calm out, do they talk to individuals following up on insurance claim? And it's obvious that English is not their first language. No-transcript, Be it good, bad or indifferent. Many times those individuals don't know a lot about dentistry either. Yes, and they're given a list of magic words that help to justify the reimbursement. And if you're supporting information does contain those magic words. I give them a list of magic words to make sure that when they have denials or delays, To make sure that they track that, understand what the insurance is looking for and give the insurance everything and more that they need to adjudicate that.

Speaker 1:

You can send too much information, no not well, you can.

Speaker 2:

Sometimes I've seen during appeals, doctors will feel it's important to question the credential and intelligence of the person who are reviewing the claims. That's probably unnecessary. Just say the claim Wow.

Speaker 1:

So yeah.

Speaker 2:

I actually I go to the meeting. It's the ADC, the American Association of Dental Consultants. Those are the consultants who work for the insurance companies. They are dentists and that kind of gets behind the curtain and I talked to them a lot about what what the concerns are, to make sure that I know what they're looking at, the things that they feel that we're doing in dentistry to abuse the system. But yeah, don't take any potshots at the person who is reviewing your claims. That's not a good idea and actually it's you.

Speaker 2:

Yeah, insurance companies actually keep a dossier on practices to which, something that I didn't know before doing this several years ago. If you're that practice who are dogged about making sure that you get paid, and if it's borderline to push, push, push, they will more than likely if it's borderline it's like this one's 5050. They'll give you benefit of the doubt and pay it because they don't want to deal with the follow up that is always forthcoming from that practice. So be that practice. If you have grounds to believe that that claim should be paid, by all means don't give up. And honestly, if it is denied on the first submission because of medical necessity, if you do file an appeal, a different dentist reviews it.

Speaker 2:

And I ask this question when I'm lecturing if you gave the same clinical records for one patient to five different doctors, how many different distinct treatment plans would be generated? And everybody goes five. And I said, well, probably seven or eight, because a couple of you couldn't figure out one. You generate two or three. Dennis, don't agree? So there again the people who review your claims. They probably don't agree either. So don't give up. Send it to one. They'll say no, I don't think you should do that. Another one, look at them.

Speaker 1:

Yeah, I think I would offices that appeal tend to get less denials. But also we don't want to be that office that is I don't know really ish towards the insurance company and the person, because we are dealing with human beings and we want to be cordial and we want to ask for maybe reconsideration, providing additional information if we can. What other suggestions do you have about a successful appeal strategies?

Speaker 2:

So sure I would. I would have that conversation with the parietal relations area. So if you're getting consistent denials on a particular service that you're providing, have that conversation. You know I'm one of your providers. We're getting fairly consistent denials on our crowns. Can you tell me what criterion you use to justify the need for the crown? And listen and give them the information that they're asking for?

Speaker 2:

You know they can't pay for something that they not supported in a way that would justify under their criteria and necessity and sometimes you can go online and that information is online as far as what they feel is justification for the need for a crown and follow those criteria and make sure the clinical record establishes those conditions and situations with that tooth that would justify the need for the crown. You know it's it. Some people say, well, that's playing the game and I said, well, it's not playing. The game is just give them what they need to be able to process. You know it's it. They have criteria and that's established. And, to be honest with you, if it doesn't meet the criteria and and they go ahead and pay that claim, they have committed insurance fraud. They paid for something that should not be paid for, so they have to maintain a certain criterion established in their plan. Otherwise they're distributing money inappropriately and probably taking advantage of the company who is providing the coverage for that patient.

Speaker 1:

Exactly and ultimately, we want our billing processes. We want to fight to get claims paid for our patients so that they can receive the care that they need because they are paying premiums.

Speaker 2:

They are their coverage.

Speaker 1:

So we want to make sure that we are maximizing on insurance reimbursement as a patient centric service, so that we are a getting every penny owed to the practice but also that that translates to the patient receiving the proper care.

Speaker 2:

And benefit.

Speaker 1:

Yes, and benefit for continuing on.

Speaker 2:

If you've done, if you've submitted, then you've appealed and you feel that it was denied inappropriately. I always encourage that patient. Arm them with everything they need, all the interaction you've had with the insurance company, give it to them and have them take it to their insurance agent or to the HR department at the business they're working at and then for that, when that HR person reviews that contract for the next term and that insurance company has been difficult to deal with, they deny a lot. They don't pay for those services that they are covering their employee for. Then they're going to look for another insurance carrier moving forward. Now that gets the insurance company's attention as well. It's kind of like okay, we're being a pain to this employer and more than likely when they go to renew this contract they probably going to look for somebody else. So maybe we need to take that into consideration when we deny all these claims.

Speaker 2:

So, that that's one of my last ditch efforts suggestions to take it to the HR department. If it's one of those, if you're that person who is buying the insurance coverage yourself, go to the person who sold it to the insurance agent and say you know I paid for this and they aren't paying for this crown, that I should be covered under this, and then your agent can take action as well. You know it, it follow the money in the insurance company. If you get their attention that way, they don't lose those contracts. They don't want to lose that. That revenues from the employer or from that insurance agent. So be aware of that as well. You can use that as a little bit of leverage as well.

Speaker 1:

Well, I think you and I can. I always say this every time we're we're ending a long conversation about this topic, I always say we can go on and on and on about all of this stuff, because we both geek out about compliance and billing and maximizing on insurance reimbursement. We are going to be talking about this at our upcoming event and Chantilly Virginia on November 3rd. I'm really excited about that and that's going to be a lot of fun. Before we close out, dr Shelburne, if there was one piece of advice that you could give in general, what would that advice be?

Speaker 2:

The three things that would be most important to maximizing legitimate reimbursement to protect and defend your practice and to help you sleep well at night. The three things are documentation, documentation, documentation. So, even even though you think it's the least sexy and enjoyable part of your practice, it will ultimately bring so many rewards and peace of mind that do it, just do it. It's it's. It's difficult to get the system down, but once it's in place it is easy, and much easier than trying to do a piecemeal if you don't have a system together.

Speaker 1:

I love that and it is. You're right, it is not the sexiest part of the day, or, but it is one of the most impactful and I love that. You said if you want to sleep at night, documentation, so I agree with that and, with that being said, I want to thank you for being on the podcast and I look forward to our future conversations about everything related to billing.

Speaker 2:

Erica, thank you, looking forward to November. It's going to be great. Thank you for the invitation. If anybody has any questions, if they want to reach out, that's great too. You'll share my contact information.

Speaker 1:

I'm going to put your information in the show notes. So if anybody has any questions for Dr Shelburne, he does answer his phone, his cell phone, and that's a funny story. I was so surprised and shocked when I called the number on his website and he picked up and said Hello, he actually picks up his phone, absolutely, if you have any questions. There's no excuse to not understand what proper documentation looks like and you have the ultimate resource to reach out to. So but, that being said, I will see you soon and talk to you later.

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Ericka Aguilar

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