The Dental Billing Podcast

Dental Billing Framework and Systems (Part 2)

• Ericka Aguilar

Share episode

Unlock the secrets to a thriving dental practice with our latest episode, where we delve into the world of insurance profiles and KPIs with a laser focus on the top PPO plans that are shaping patient volume. Ever worried if your patient counts are accurate? We tackle the crucial task of cleaning up patient data, ensuring the numbers you see reflect the active patients you serve. This isn't just about numbers; it's about the heartbeat of your practice. Discover how understanding insurance AR, days in AR, and perioperformance percentages can unearth hidden revenue gems, especially within your hygiene department.

The unsung heroes of dental billing take center stage as we explore the meticulous world of dental assistants and their pivotal role in handling x-rays and clinical documentation. Their precision not only streamlines the billing process but is also a frontline defense against fraud. With structured decision-making tracks and performance meetings, we guide you through revolutionizing your practice's efficiency. We share real patient scenarios to empower hygienists in their treatment discussions, emphasizing consistent care and the bedrock of transparent communication.

As we wrap up, we lay out actionable strategies to supercharge your billing department's performance. By auditing and refining procedures, we show you how to achieve predictable outcomes and more robust collections. Accountability doesn't have to be a dirty word; with regular meetings and consistent oversight, we emphasize the impact of a well-oiled team on maintaining the systems we advocate. Tune in to transform your dental billing from a routine task into a strategic asset for your practice.

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:

Okay. So, moving into insurance, we're now in the third part of the framework. We create an insurance profile and we have found, as we have worked with many offices to optimize their billing systems, we have found that the insurance profile to a dental practice that's contracted with PPOs is typically made up of about five plans that make up most of the insurance money. And so we take a look at those top plans by quantifying how many patients are attached to those plans, and I can tell you Delta Dental is, almost 100% of the time, number one, and so we will then go, okay, delta, and then Blue Cross, blue Shield. As an example, you know SIGNAB, but you'll notice, if you really analyze your insurance profile and you create this, it's a very interesting mix because what we have learned is that you have your top five, but really, within the top five, the number one and number two make up most of your insurance patients, which is interesting because we have profiles that look like this Delta Dental will have 1200 patients attached to that plan. Then we have Blue Cross, blue Shield, which will have 328, and then it will just drop, but they still fall in the top five. So then you might go to Aetna, which will have 47, and then you'll have, let's just say, gija will have 17, but they're still in your top five. So it's a very interesting profile to analyze, because it just drops off after number three, but those last two are still in your top five. And the other thing that we want to look at is what percentage of collections does each plan contribute to overall collections? So you would think that, because you have 1200 patients attached to Delta, that Delta would make up the majority of that percentage. But sometimes we find that, because we haven't cleaned up the systems, you have 1200 patients attached to Delta, but the reality is only 600 of them are active patients, truly active patients. And that's why we like to do the cleanup before we get into all the framework, because now we can accurately state how many active patients you have attached to that plan. As we move through the framework, the picture gets clearer and clearer as to what systems need to be created, what gaps need to be filled, and then we can move into training the team so that we don't recreate this mess. So that was the insurance bucket, and now we're going to move into key performance indicators. We want to make sure that we are monitoring our key performance indicators. So first we identify where you are and then we are going to train the team to maintain or to trend in the right direction in getting our KPIs under control. So some of the KPIs that we look at is going to be insurance, ar and days in AR.

Speaker 0:

We also like to incorporate periopreformance percentage because this really helps to identify what we are leaving on the table in terms of billing and coding, because I know that our hygienists are doing a gingivitis cleaning but documenting for a pro-fee. And that's why we have Jen, our hygiene coach, on our team who works with our hygiene teams within our clients offices to coach them, train them on the different decision-making tracks between a pro-fee, a gingivitis cleaning and a periopatient, and she's very good at helping them to move that pro-fee patient into a gingivitis state without overwhelming the patient. Because a lot of our offices, as we examine periopreformance percentage, a lot of times they think that they're doing better than they are. But then when we show them the hard data and we say you should be at 80% or better and we're currently at 26%, it can somewhat feel like what do you mean? I'm at 26%". So Jen helped to train them, to teach them how this percentage? First of all, how did we come up with the percentage and how are we going to move closer to the 80% performance percentage? And we have found in working with hundreds of hygiene teams, the hygienist is doing a gingivitis cleaning or an isolated area of perio. However, the lack of documentation is where we lead the opportunity to code and bill and get reimbursed for what we're actually doing. So we want to monitor the perio performance percentage so that we coach to success and also we get paid for what we're actually doing.

Speaker 0:

On a side note, I had the pleasure of being a keynote speaker at an event where it's predominantly hygienist. It's called Brown Girl RDH. I interviewed Martell Koch, the founder of Brown Girl RDH, on one of my previous podcast episodes and you can go back and listen to that because she's got such a powerful life story. If you need some inspiration, go listen to my girl, martell, because she's extremely inspirational. So I had the pleasure of speaking to a roomful of hygienist and I asked the question because I said to the audience I never have an opportunity to speak to so many hygienists at one time. So, if you don't mind, I'd like to ask you how many of you would admit that you document bloody pro-fies, but you may be going sub-gingival in some areas, with or without periopresent. Every hand in the room went up and so this is where the coaching comes into play, where they just didn't know how to document for what they're doing. A lot of the hygienists didn't even know that we had a new code introduced a few years ago for a gingival inflammation cleaning or, as Jen refers to it, as a therapeutic cleaning. So it's just important as we monitor this KPI, it has such an impact and it is a part of the billing department, because most of the opportunity when we optimize an office's billing department is left in the hygiene arena. And so as we monitor this and we have many other KPI's that we monitor in the billing department, and all of these are designed to create ease and take the guesswork out of what to do next for every team member, because everybody on the team affects the billing department.

Speaker 0:

You may not think, as a dental assistant, that you have any impact on the billing process. However, the attachments and the x-rays and the clinical documentation all matter for me as a biller so that I am able to submit a clean claim. And when we submit blurry intra-orals or cone cuts, elongations, the x-rays foreshortened on the anteriors or elongated. It's a fraudulent x-ray and I'm going to use that term because insurance companies are not supposed to pay claims with subpar x-rays. There is a standard on how our x-rays are to be submitted and when they are below standard, then the insurance company, by paying that claim with those substandard x-rays, has also committed fraud. So we don't think about things like that. But when we put things into systems, we can talk about those things. So, as assistants, you are kicking off the billing cycle with your x-rays. So the better the x-ray, the less fraud we commit. And I am going to continue to use the F word because I want everybody to understand that we all have a piece of responsibility within the billing process and I don't want my assistants to think, just because you're an assistant and you're not working in the front, your efforts don't have an impact on the billing process, because they really do.

Speaker 0:

Okay, so we talked about a few KPIs. Let's go into the next, which is going to be workflows and decision-making tracks. I cannot emphasize this section of the framework enough. This is my favorite part of the framework. It's fun, fun for me, fun for my team, fun for your team, because this is the part of the process, or the framework, where the magic really happens. This is where we take the guesswork out of what to do next. This is like the checklist manifesto for dental billing departments. If you haven't read the book Checklist Manifesto, it's a very good read and it talks about checklists for everything, and I love checklists and workflows and taking the guesswork out of what to do next. I don't know if you heard about what happened recently with Alaska Airlines and the door flying off the flight. The pilots have a checklist of what to do when a door flies off the airplane midair. There is a checklist for that, and when we think about a checklist or a workflow, it just makes your job that much easier when we know we have somewhere we can reference on what to do next. It is not going to have every answer for you, however. This is the part where we create the guides for your team to understand how you want your practice to run.

Speaker 0:

We have this wonderful guideline and it's for the hygiene department and it literally is three tracks and it says prophy patient, gingivitis patient and periopatient, and it walks through things like how to determine which type of cleaning I should be documenting, and so the prophy patient is going to be more consistent with their care. They are not going to have any bone loss or attachment loss. It just gives a whole list. Then next to it is the gingivitis patient, and this patient is less consistent with their care and they have red, puffy gums. Their pocket depths are greater than that of a prophy patient, and then we have a whole track for the periopatient so we can clearly identify which type of cleaning the patient qualifies for.

Speaker 0:

What type of conversation do we need to have? Because a lot of times this is where it gets a little sticky for the hygienists. We have an existing patient that's been coming to the practice for five years and now the patient is gingivitis. Because you have this decision-making track, you realize, okay, this patient has been a gingivitis patient. How do I have the conversation with the patient and inform them that they do not qualify for a healthy cleaning?

Speaker 0:

Now we are moving into treating disease. How do I have that conversation with them? And that's where these workflows, scripts and what to do next are available to the team, so that there's no disruption in flow. At least that's what they're designed to do. It's not going to create a perfect day, but it is going to help improve productivity because we have something that the hygienist can look at and say okay, I know how to start this conversation. I have an example of a script and I'm just going to open up the conversation this way, and that is better than the hygienist stopping going to the front talking to the front about this gingivitis or therapeutic cleaning that the patient now needs. It eliminates a lot of things that potentially would have happened.

Speaker 0:

But now, because we know what to do next, the magic's going to happen and that's the point. We really want to take the guesswork out of everybody's role so that ultimately, a better care, better periopreformance and also higher reimbursement and we've done our homework friends we really have on average when we work with a dental practice. On average you might have, let's say, that we do 20 prophes a week I'm using a very conservative number Out of those 20 prophes that you have scheduled for the week. We have ran our numbers and we have found about 40% of the prophy patients that we are seeing are actually gingivitis patients and with that we encourage the use of laser. We encourage bringing that patient in every three months until we reverse the signs and symptoms of gingivitis, because we emphasize to the patients that gingivitis is reversible and perio is not, and we're on the cusp of perio. So just having those workflows and what to do next type of things really is where you get to see that magic happen.

Speaker 0:

Okay, moving into the last bucket, the last main functional area reports and meetings and this is where another area where I find we don't have meetings around the billing department performance. Typically, I don't see meetings around hygiene department performance. I don't see meetings that actually move the needle. I see a lot of offices that have meetings and a lot of times we hear things like okay, this month's production goal is $80,000. So far we've collected $56,000. We're almost there. It's really uninspiring and I'm not necessarily saying that we want to walk away from a billing meeting feeling inspired, but we should feel like we accomplished something, we should feel like we're trending in the right direction and we should see the needle moving.

Speaker 0:

In the reports and meetings section of the framework, some of the things that we want to implement are protocols around what information you would like delivered to you from each report, and that's where we're going to sit down and review the billing reports and we're going to identify what you would like delivered to you as the practice owner or office manager, from your billing team. Things that you want to review are going to be what did our previous report look like? What amount of insurance money was owed to the practice versus this meeting? Did it go down? Did it go up? If it went down, how much of that was collected versus written off or adjusted? So we really want to sit in these meetings to identify patterns. I want to review denials together. I want to look at EOBs of all denials from in between our last meeting. I want to review that, not to point fingers at anyone, but really to identify patterns of potential insurance bullying, because insurance bullying is real and we want to be able to identify why we are getting so many denials from SIGNA on buildup versus Delta Dental for SRPs. We want to establish patterns, identify them and then address them head on with the insurance company. We want to review our adjustments together.

Speaker 0:

I really highly believe that as a practice owner, you should give your bill or whoever is handling adjustments decision making space around how much can be adjusted before it needs to be brought into the meeting, so you can freely adjust up to $100. I don't need to know about that. However, anything over $100, I want you to have ready to review with me in our next billing meeting so that we don't have adjustments of $3,000, as I have seen recently. In one office that I worked with, we did the optimization program, and this office does use a third party, and the third party was just adjusting anything that they saw fit without rhyme or reason, and we saw a couple of adjustments that were $1,000 and one was as high as $3,300. And my doctor had no idea that, a this was happening and, b that they were making such large adjustments, and so we put protocols in place and informed the third party that they can adjust freely up to $100. Anything over $100 needs to be brought to the office manager's attention and at that point she can make the decision on how much to adjust, appeal and moving forward, what to do next. She has a workflow or a checklist, if you want to call it, on what to do next when this is brought to her attention. This process of optimization and cleanup because let's just call it what it is it's a cleanup, because we didn't set up systems in the beginning, so now we have to clean up and then optimize. This entire process is heavy on the front end because there's a lot to do, but I promise setting up these systems will give the billing process more predictable outcomes and that, my friends, I know that that's what you want Do not judge the performance of your billing department based on denials.

Speaker 0:

I've heard this a lot, because I used to ask a question at the beginning of my workshops on a scale of 1 to 10, how would you rate your billing department performance? And I have since stopped asking that question because I was getting a lot of misinformation or misunderstood answers because it was going to either be based on the biller performance, and that's why I emphasized in the beginning Billing department performance is not the reflection of your biller, it is a direct reflection of the lack of systems in place, and most offices never did that. They never implemented dental billing department systems. And that's why setting up these systems to have more predictable outcomes is important. Because the other answer that I would hear is that we don't get denials, so we must be doing things right.

Speaker 0:

And my rebuttal to that is just because a claim gets paid does not mean you build it Compliantly. I used to say correctly, but now I say compliantly, because a lot of times we give insurance companies excuses to ask for their money back because we're sending in subpar X-rays or so many other reasons that we give them to ask for their money back. Now I'm not saying that you need to give them their money back when they make a request, but we definitely want to make sure that we are submitting claims that are clean and we are anticipating and looking at every angle from the insurance standpoint as to a possibility of denial or refund requests. We want to avoid that at all costs. So again, just because your claim was paid does not mean you build it Compliantly.

Speaker 0:

A perfectly clean claim, in my opinion, is going to be one that gets paid right away the first time we submit. No additional information is needed and we do not run the risk of having to give the money back. That, to me, is a perfect outcome. I can't guarantee that Nobody can guarantee that 100% of the time but again, having your systems in place is definitely going to allow you to have a more predictable outcome with your billing process and once these systems are in place, you're going to have clarity on how the billing department is performing and catch any challenges, gaps and fix them immediately. Your biller is going to understand what to monitor and how to deliver that information to you. So this is going to be less stress, fewer questions and increased collection. So that's really the ultimate goal is to have predictable outcomes and less stress in the billing department, and shifting the accountability from the biller to systems will make the billing department meetings more productive and really laser focused on the numbers and patterns that we want to identify in those meetings.

Speaker 0:

Finally, before we close out on this topic, all of this is great and I mentioned this at the beginning of the episode but what good is it without accountability? And again, accountability is what gets the needle to move. Meetings need to happen as scheduled and all members you've decided to be in the meetings should be present, and there should be no exceptions to that rule. We want to run the billing department as if it is a business, because it is, and when we have an office manager who is holding the team accountable to all the things, after all the effort you go through to clean up and then optimize, you cannot maintain the clean systems without accountability.

Speaker 0:

So I hope that this episode has given you some clarity on how to optimize your billing department and create more predictable outcomes with your claims. So, with everything that we just went over, my hope for you is that I have inspired you, given you a place to start so that you can go back to your office and implement cleanup and optimization. Thank you for listening to this episode and if you liked the information that I provided, please leave me a review. I always strive to provide relevant and up-to-date information so that you continue to enjoy these episodes. Ok, my friends, I will see you in the next episode.

People on this episode

Head Shot

Ericka Aguilar

Host