The Dental Billing Podcast

Dental Billing Framework and Systems (Part 1)

• Ericka Aguilar • Season 7 • Episode 6

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Have you ever felt overwhelmed by the labyrinth of billing and coding in your dental practice? Prepare to navigate this complex terrain with confidence as we dissect the art of billing department optimization. Our conversation steers you through the process of decluttering your practice management software, much like tidying a hoarder's abode. We confront the common fear of conflict head-on, revealing its true nature as a growth catalyst, essential for the evolution of your billing operations. With Dr. Roy Shelburne's harrowing story as a backdrop, we underscore the dire consequences of inadequate billing knowledge and the non-negotiable need for compliance in every patient transaction.

Dr. Shelburne's narrative serves as a stark wake-up call about the risks of neglecting proper billing practices—a lesson he learned the hard way. We unpack the six-part framework that transforms billing departments from chaotic to controlled, discussing everything from software setup and insurance complexities to the formulation of Key Performance Indicators (KPIs). Our discussion highlights the pivotal role office managers play as coaches, guiding their teams through the transformation with dedicated coaching and unwavering accountability to breathe new life into your practice's financial health.

And if you've ever questioned the potency of your dental practice management software in crafting precise treatment plans, this episode is a treasure trove of insights. We dissect the software's often-underused capabilities, emphasizing meticulous training and the exacting entry of insurance benefits. By concentrating on these strategies, you'll learn how to leverage technology to its fullest, ensuring your treatment plans are not only accurate but also reflective of the cutting-edge advancements these platforms continuously integrate. Join us for a journey that promises to fine-tune your billing efficiency and catapult your practice's revenue to unprecedented heights.

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 0:

In today's episode we are diving into the details of optimizing your billing department. What do I mean by optimization or optimizing? I'm talking about the many conversations I have with practice owners or office managers who have simply lost control of their billing department. Maybe you have a little control over your billing department and you sense that a cleanup is in order. When I am talking about optimizing a billing department, I am talking about something like going into someone's home who has been hoarding information or hoarding things. If you haven't seen the show Hoarders, these are individuals who keep things for decades and they just continue to pile up. Same thing happens in our billing systems. We have patients in our practice management software who should be archived or inactivated, but we continue to hoard patients and we don't clean up the system. This is what I'm talking about. When we're optimizing a billing department, it starts with the declutter of the information that we have within the practice management software. We first have to start by cleaning the items that we have hoarded or kept that no longer need to be factored into our reporting system. We definitely want to start archiving and inactivating the patients and their accounts so that now, when we are looking at our reporting systems, we are looking at active patient performance only. This is the most commonly overlooked area. Keeping your systems clean, doing an annual spring cleaning of your patients, active archive balances we really need to get ahold of that. That's one element of the optimization process. This is also going to involve setting up new systems and then training your team. This is where I find we have the most conflict when we are introducing new systems to a process or to the department. People in general do not like change. However, we have to understand if we want to maintain and optimize our billing departments. We have to understand that with change comes conflict.

Speaker 0:

I'm going to park there for just a second and I'm going to talk to you a little bit about conflict. I used to do this exercise in one of the trainings we did when I used to teach dental front office. For those of you that don't know, I used to teach dental front office to individuals with no dental background. Think of it like a dental assisting program, but strictly front office. That's the closest I can get to giving you an example of the curriculum. It's for individuals coming from other areas or backgrounds. Some of them were working in warehouses and wanted to work in a dental office. They took our course to learn how to work on the front part of a dental practice. Within that curriculum, we had a leadership day. In that leadership day, we wanted to prepare our students for change.

Speaker 0:

One of the things that we emphasized is that with change comes conflict, and without conflict there is no growth. We would have the students right on one side of a piece of paper conflict and then on the other side of the piece of paper we would have them write all the words. We would time them maybe three minutes and say write all the words you associate to conflict. This is really where I got to see behind the curtain about what most people think about conflict. The reason I'm talking about this is because, as you optimize a billing department, the individuals within the department tend to not like change. However, if we keep doing things the way we've been doing them, then nothing's going to change and we're going to continue to hoard information that we don't need to have. Then we're not going to be able to create the change that's needed in order to ultimately increase collections and improve patient care.

Speaker 0:

Going back to this word conflict, typically we would see almost 100% of the time I'd say 99.9% of the time we would have students write things like scary argument loud, don't want to deal with it. So a lot of avoidance around conflict, and that seemed to be the consensus. Rarely ever would I see someone write something like growth or good. I would more often see bad, that exact word, bad. So when you want to create change, when you want to optimize, when you want to create ease of flow in your billing process, it is going to require that, a we clean the system up and then, b we train our team and let them know. This is now how we run our billing department, this is how we do business in the billing department, and sometimes during that training you're going to have some conflict because people don't like change in general.

Speaker 0:

So I also like to emphasize, as my team and I move into the training and the optimization, we are also going to share a top level analysis that we pull from the system and it allows us to see where the gaps are in the revenue cycle. And I emphasize to the teams that this analysis is not biller performance and I really want to emphasize that this is not based on an individual's performance. This is based on how well the billing department was set up from the get go and I can tell you without a shadow of a doubt, I have yet to see an office that had systems in place when they opened their office. Typically, we work with offices that have been open for two plus years, but I can tell you without a shadow of a doubt, none of the hundreds of offices that we have worked with have had systems put in place when they opened, when they were a startup. And that's okay because we can clean it up.

Speaker 0:

But it's going to require cleanup, it's going to require training, it's going to require willingness from the team to implement change, because an optimization program is only as good as the team that's going to be implementing it, and if the team is not on board with the change, we're going to have very little success. So, after we do the training, it's going to require ongoing coaching, and I'm speaking to my office managers. You are the coach of the practice and your job as an office manager is to get your team to high performance. That's the ultimate goal of a manager is to get the team into high performance gear, and how you do that is by coaching your team to success. What good is doing any cleanup, any optimization, if we don't have accountability built in, if we don't have coaching on a regular basis. That is really where we start to see the needle move is through the coaching that is offered not by an outside third party, but by an effective office manager who can motivate the team to be in alignment of North. And that is something that I firmly believe in that once we do the cleanup and we get the systems in place, if we have a team that's moving in alignment of North, everybody's pulling in the same direction. We all believe that this is a good thing for the practice. You will see the ultimate results from optimizing your billing department.

Speaker 0:

All too often I see practice owners hiring a biller or an office manager with a certain amount of experience and then expecting them to work magic and create systems. And the challenge here is that while we have a ton of experienced and very knowledgeable individuals in the billing arena, most of those individuals do not have systems. And why should they? Their expertise lies in the art of dental billing. That is their craft. I would much rather have systems in place and marry that with this knowledgeable individual who has really honed in on their craft of dental billing and watch the sparks fly. But most of the time what happens is we have individuals who are really good at their craft and they start at a new office and it's a mess because the last person had no control over the account receivables. And this individual is now feeling overwhelmed and lost and does not know how to clean this up systematically because their craft is dental billing. They're expert coders, they're expert packagers, because if you've ever listened to any of my podcast episodes and I've talked about the billing position, I say that we wear two hats. The first hat is our coding hat and then the second hat is the packaging hat. So we code the interaction by looking at the clinical notes and hopefully you are reading your clinical notes before you are submitting any type of claim and I don't want to get into that today but you are coding the interaction and then we're putting the package together. We're making sure that we have the x-ray and the narrative and now, moving forward in 2024, the diagnosis code. So we really want to hire someone for their craft, not for their systems.

Speaker 0:

When we're talking about billing, if your billing department is a mess, that is not the billers fault. That is the fault of the owner not setting up systems when the office opened and I'm going to walk everybody through our six-part framework. This is the actual framework we use when we optimize and clean up a billing department. I already talked to you a little bit about where we start. We start with the information that we've been hoarding and I referred to that as our patients Are. We cleaning up our patient base every year. We do in that spring cleaning of information and most of the time it's a no, so we start there. However, I want to talk to you a little bit more about our six-part framework.

Speaker 0:

The reason I felt compelled to even record this podcast episode was because I have had many conversations with office managers and doctors lately with concerns about compliance, especially since I just shared the stage with Dr Roy Shelburne about 20 minutes outside of DC in Chantilly, virginia, at YM Dental Lab, and we talked about coding, billing and compliance. And for those of you that don't know Dr Shelburne's story, I'm just going to be very brief. Dr Shelburne went to prison for 19 months, lost his dental license for the amount of $17,000. And I want you to think about that for a second. $17,000 put Dr Shelburne in federal prison for 19 months for $17,000. This was money that the insurance companies deemed he was not entitled to, and the reason why this happened was simply because there were things that the biller didn't know. She didn't know, and this is where systems and workflows and compliance all come together, and that's really, at the end of the day, we want to maximize on every penny owed to the practice and squeeze every penny out of the insurance company while at the same time, being compliant and patient-centric.

Speaker 0:

So very important that, as we move into this framework, it's not always about the money. It's also about compliance, and I've had several conversations with individuals that have called me. I did an Instagram live and in my live I talked to fellow billers and I said if you are working for an office that is requiring you to bill before the documentation is done or asks you to bill before the documentation is done, go find another office to work for. We want to make sure that we're doing our part as billers and being compliant in our own regard as well. So when you know better, you do better. I've also had numerous conversations with startup practices and again, I can unequivocally tell you that when opening their first practice, setting up billing systems is usually the last thing on a new practice owner's mind. However, you fast forward a few months and they find themselves dealing with messy AR, surprise patient balances, denials, incorrect fee positioning and that unsettling feeling of not having control over claims and not seeing the insurance checks reflecting what was produced. I hear often from doctors that I'm busy, we're busy in the back. It just doesn't feel, even in terms of reimbursement, and I totally get that. And we can avoid that feeling when we have systems in place.

Speaker 0:

All of this boils down to not having billing department systems in place. So what do these systems look like? Let's first break down this billing department framework that I've been teasing you with and let's go through each part of the framework. This is the framework that my team and I use when we are optimizing an existing billing department or setting systems up for a startup. The framework has six main functional areas, so I'm just going to go through those areas and then we have a list of items that we check off for lack of a better term under each main functional area of the framework. So I'm going to give you a few pieces of each list under each area.

Speaker 0:

So the first area that we have in the six parts of the framework is going to be set up. Second is going to be software. The third is going to be insurance. The fourth is KPIs, or key performance indicators. The fifth is workflows and decision making tracks and we customize those, and finally, reports and meetings.

Speaker 0:

So let's first go through the first part of the framework. The first part of the framework is and I want to remind everyone that the framework is worked after the cleanup is done. We go through the software and we start with cleaning up the patience, then moving into possibly purging the insurance companies, because a lot of times front office team members are all using the software in their own way and sometimes we're creating 20 different signaz when we should just have maybe two or one ideally. So we want to go in and we clean up the insurance, and then there's some other areas involved in the cleanup of the billing department. Once we do that, we are going to step into the six part framework.

Speaker 0:

The first area that we're looking at is setup and within this part of the framework we're going to create a coding profile for the practice, and the coding profile helps us identify utilization patterns, and here's why I have had doctors call me and tell me that they hired the best biller because after hiring this biller, their insurance collections has gone up $50,000. That is great. However, it raises red flags for me, and here's why I don't know that this individual is using codes that are outside of our normal utilization patterns and I have no control of that if I don't have a coding profile. Your insurance companies have a coding profile on file with them. The insurance companies do what is called a utilization audit and if you have a newbie or a newcomer come into the office and they start utilizing codes that you've never used before, because now they're padding claims that could trigger an audit. And so to maintain compliance and control of the billing department, the first place that we start is by creating a coding profile. Now, the coding profile is also helpful to identify patterns of codes that are underused or never used, but we are doing those procedures. So a lot of times, as we create a coding profile for the practice, we are identifying patterns and through those patterns, we are able to help the office improve coding interactions between patients and the providers, and it really helps with increasing collections for things that we're doing but not getting paid for.

Speaker 0:

Another area that we look at when we're talking about setup is UCR fees. Where are your UCR fees for your area, for your zip code. Ucr fees are set up nationally through the National Dentist Advisory Service and we take a look at that data and we make sure that the UCR fees are properly positioned for your area. Those are the two main things that we do as we are moving through setup. We have a list of 20 things that we do, but those are the two main and just with those two improvements alone, if we were to not do any of the other 18 things under setup, those two would definitely help increase collections just by themselves.

Speaker 0:

So setup is the first main functional area that we look at and then we move into software, and some of the things that we see within the software portion of the framework is that providers are not set up correctly. We see that very commonly. The other area that I find we should set up but does not happen is the do not bill codes, and what I mean by that are these are procedures that we are never going to bill to insurance, even if it's a in-house code delivery of a crown code that you made up and you have your own in-house. We want to make sure that all of the codes that are never going to be placed on a claim form are set up as do not bill and we find this gets overlooked and then it creates havoc as those do not bill procedures get posted to the patient's accounts and they end up on procedures not attached to claims and it just creates a mess for the biller. So when we as practice owners set up our fees, we want to be very mindful of do not bill codes. So any of your in-house codes, any of the things that you just never plan on billing to insurance, then you want to set those up as do not bill codes.

Speaker 0:

And finally, within the software, we like to make sure that our software calculates treatment plans accurately. And this is very tricky because we work with so many softwares. We have to make sure that we know how to use that software and we test it out and make sure that it's giving the offices accurate treatment plans. Because ultimately, if you have a powerful software like Dentrix or OpenDental, you should not have to manually calculate your treatment plans.

Speaker 0:

And if you find yourself manually calculating your treatment plans, that is because you are not using the software to its full power. Especially with the way that these softwares are set up to be user-friendly, it should not be very hard. So if you find yourself manually calculating, we might want to get some training. We may want to see how the front office individuals are inputting the breakdown of benefits so that it matches what is input into the payment tables and all of the details like downgrades, can4quads of SRPs we've done in one day. Does gingivitis cleaning get downgraded to profi? We have to have all those details and these practice management softwares are getting smarter and smarter with every update, so we want to make sure that that is happening. Can the software calculate treatment plans accurately? So that's going to be the second part of the framework.

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Ericka Aguilar

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