The Dental Billing Podcast

Billing for Benefit vs. Billing for What Was Done

• Ericka Aguilar • Season 8 • Episode 1

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Embark on a voyage through the complex seas of dental billing where precision and integrity are your most trusted navigators. We dissect the treacherous practices of billing for insurance benefits instead of actual services, exposing the hidden icebergs of fraud that could sink your dental practice's reputation. From the misuse of X-ray codes to the critical need for accurate clinical documentation, we illuminate the path to ethical billing, ensuring that your practice thrives financially while delivering top-notch patient care. Discover why correctly identifying procedures like periodontal maintenance isn't just about compliance—it's about honoring the trust your patients place in your hands.

Steer your practice towards the safe harbor of success by mastering the art of PPO negotiations, a skill oftentimes as overlooked as it is vital. Listen as we share insights on the power of laser bacterial reduction treatments in the fight against gingivitis, and how such protocols can not only improve patient outcomes but also boost office production. We'll delve into the importance of patient education, helping them understand their condition and how it aligns with their insurance benefits, creating a win-win scenario for their health and your practice's financial well-being. Charting these waters may seem daunting, but with our guidance, you'll navigate them like an expert captain, confident and in control.

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:

Have you ever heard of the book Eat that Frog? It's written by Brian Tracy and teaches a task management concept that's very easy to understand. Let me break it down for you Basically. If I were to give you $1 million to eat a box full of frogs and friends, these frogs represent your tasks that you need to execute on a daily basis. So your daily task management list. If I were to give you a million dollars to eat that box of frogs, which frog would you start with first?

Speaker 1:

A lot of you are thinking what in the world does a box of frogs have to do with billing? So what I want to do is I want to take this concept of eating the biggest frog in regards to task management and transfer that concept into tackling the biggest threat that I see in the dental billing arena, which is billing for benefit rather than billing for what we do. And there are several ways that dental billers are unknowingly do this because, let's face it, bad habits are passed down from generation to generation and we got to break these habits. I'm going to give you a list of ways that we are billing for benefit and harming our bottom line. Here is a list of procedures. I see a lot of offices bill for benefit rather than for what they are doing. Let's start with X-rays, the pano and four bite wings versus an FMX. I see a lot of offices that bill for an FMX because what I have heard is the insurance company downgrades it anyways, so we're just going to bill for an FMX. That is a prime example of billers billing to benefit rather than billing for what we do. Another example is billing for bite wings and a couple of PAs to avoid the FMX denial Again, billing for benefit, not for what we're actually doing. Billing for a pano when the patient is not eligible for an FMX. We have to understand that an FMX is made up of as many intraoral films as the doctor sees fit. It is no longer required to do 14 to 18 intraoral bite wings and PAs in order to justify billing for an FMX. However, those are intraoral photos. That's the key term there. When you bill for a pano, you're billing for an extraoral film. So completely two different services and they are not interchangeable, so you don't get to bill one when one is not eligible for the other. That is another way that we are billing for benefit, not for what we are actually doing and the way the insurance companies are going to see this, friends. They're going to see it as insurance fraud. You want to be very careful that you are not engaging in these types of practices.

Speaker 1:

Moving on to another set of billing to benefit is when we are billing for a comprehensive exam and the patient should have been charged for a period exam, so D0150 billed for a patient who should have been billed for a D0180, the comprehensive periodontal exam. And that's when we have new or existing patients who have been diagnosed or show signs of periodontal disease and so we are billing to benefit. We are not billing for what we are actually doing. Or in some cases, a lot of billers and doctors for that matter don't realize that you can bill for a period exam even though you're not a periodontist. I do get that question a lot. I thought that was for a period or periodontist to bill for their comprehensive exam. There is nothing listed in the CDT book that stipulates it is only for a prostodontist or it's only for an oral surgeon. Anybody general dentist, specialist can bill for any of those codes if it was legitimately done and documented in the patient's chart.

Speaker 1:

Moving into another area where I see a lot of billing to benefit. And this is probably where I'm going to say the biggest frog is, and I'm going to talk about cleanings the biggie in this arena is going to be billing for a prophy. When we did periomaintenance I see this a lot I see offices that will bring the patient in four times a year and alternate what they bill. So we will bill one visit periomaintenance and then the other visit because we know that the insurance company is going to only pay up to a profi benefit. We're only gonna bill for the profi. And that is another example of billing for benefit, not billing for what we're doing. We have to keep in mind, friends, that what the insurance company decides to pay for is the benefit. What we do is what we charge our patients for. So when the insurance company is only going to pay us up to a profi benefit, it's important that we charge the patient the difference to the fee of the periomaintenance. Whether that's in network or out of network, the patient is responsible for the difference. And this is where it gets sticky, because if we don't understand insurance benefits versus what we actually did and payment guidelines, we're not gonna know how to present treatment to a patient adequately.

Speaker 1:

Another example is going to be when we bill for a profi, but we actually did a gingivitis or gingival inflammation cleaning D4346. This is probably the most underutilized code I see in offices across the country. This is another area where we need to get better at clinical documentation A and B understanding what it takes to get a gingival inflammation or gingivitis cleaning paid by insurance. And we're gonna talk about that here in just a minute because, in my opinion, this is the biggest frog we need to eat in the box in terms of tackling the silent threat of billing for benefit rather than billing for what we're doing. We'll come back to that in just a second. How about billing for a profi when we did limited SRPs during that profi? What about billing for a profi when we did a cleaning of a partial denture during that visit?

Speaker 1:

We need to make sure that, as we are billing for benefit, we're also billing for things that we can get paid for, and we want to make sure that we are taking advantage of every opportunity to get higher reimbursement from the insurance company because it's to the patient's benefit, right? We wanna take advantage of the patient's benefits because they are paying their premiums and, in my opinion, insurance companies are double dipping because they're taking the premiums and they're denying claims and we have to learn how to get better at the insurance game. Another area that I see we miss the mark and bill for benefit and lose money is billing for downgraded procedures and not what was done. I see this happen often. We do an implant, the benefit is paid up to the least expensive alternative treatment, like a partial denture, and we bill for a partial. We want to make sure that we are billing for what we are actually doing A PFC crown, but we bill for the downgraded benefit of a full metal crown, composite fillings that are billed at the amalgam rate, buildups not being included on the claim form and, finally, not placing the buildup on a crown claim because the buildup is denied. So often we've given up, we've stopped the good fight and I have heard a lot of that in my workshops. In the side conversations that I have. A lot of billers have approached me and asked me if they should continue to put the buildup on the claim form even though insurance companies are flat out denying the buildup, and my answer is always a standard yes when they deny the buildup and incorporate the payment for the buildup with the crown.

Speaker 1:

Appeal, appeal, appeal and appeal again. Insurance companies have their way of understanding who appeals claims and who does not. For offices that get a lot of buildup denials, or they get a lot of SRP denials, or they just receive more denials than a normal practice would. Typically, it's because we're not appealing, we're not challenging decisions that insurance companies are making for us. So appeal, appeal, appeal. If you need to know how to start the appeal process, I will put a link to a podcast episode I recorded a couple years ago about how to appeal.

Speaker 1:

In the show, note, let's start eating those frogs and we're going to start with frog number one. And so again in this book, eat that Frog. It's teaching you task management and it teaches you in a very simple concept that if I were to give you a million dollars to eat a box of frogs, which frog would you start with first? And a lot of people will say well, obviously I'm going to start with the biggest frog. So, taking that concept out of task management and transferring it into tackling the most important challenges that we see in the billing arena, one of which is billing for benefit, I'd say that the pro-fee versus the gingivitis cleaning is probably our biggest frog to tackle and fix, as we fix, this whole billing for benefit situation. So here's what I've heard in my workshops and the feedback that I get in conversations I have with doctors, sometimes with hygienists and with billers.

Speaker 1:

I have heard that the reason we bill for a pro-fee, even though we know we did a gingivitis cleaning, is because Delta Dental, for example just had this conversation with a dentist in Virginia pays more for a pro-fee than a gingivitis cleaning. So we are going to bill for benefit. We're not going to bill for what we actually do, or the payment for a gingivitis cleaning is downgraded to a pro-fee. And my theory here is that we don't understand enough about the difference between compliance regulations, the golden rule document for what you do and payment guidelines, right. So we need to understand that it is super important that we're documenting for what we're doing and the claim matches what we are placing on the claim form, matches the codes we are putting on the claim form, matches what the documentation says. That's why we don't bill before the clinical documentation is done. Additionally, clinical documentation needs to include the reason why we are doing a procedure, aka a diagnosis code.

Speaker 1:

Our hygiene coach, jen I love Jen has an example of what clinical documentation for a gingivitis cleaning would look like versus a pro-fee. Some of the differences include documenting the patient's inconsistency with re-care, the state of the tissue if the bleeding is localized or moderate, versus documentation for a pro-fee, which would look more like a patient with more consistent re-care, pink tissue and little too light bleeding. So there's a very big difference in the classification of a pro-fee versus a gingivitis cleaning patient. But More often than not, what I get as a biller is a bloody bib profi. That was documented.

Speaker 1:

So my hands are tight, I have golden handcuffs, I can't do anything because I'm just the biller and I have to follow my compliance guidelines and bill for what was documented. However, we know that when there's more than 30% generalized bleeding present, most likely you're treating disease. Why are we billing for a profi? Again, because my hands are tied and I'm not the clinician and even though I know what I'm looking at, I cannot change the documentation. And so when we're talking about billing for benefit versus billing for what we are actually doing, we're getting down to the core of the issue, which is clinical documentation that represents what we are actually doing versus what was documented, and I cannot bill for anything outside of the documentation. So for just a second, let's remove what the benefits are. How did we get to the point of billing for benefit and not for what we actually did? I'm going to tell you how.

Speaker 1:

Insurance companies, friends, are not playing fair. They never have, and they're forcing our doctors to look for ways to be fairly compensated. And although this is the case, we still need to be mindful of compliance. When you have a patient who has symptoms of disease, we need to document both the diagnosis and the treatment of the disease, regardless of the reimbursement. Don't come at me. I am not trying to say that we need to settle for lower reimbursement, but I am just saying let's not be short-sighted of this one visit. Let's take a look at the bigger picture.

Speaker 1:

My theory around this is that when a patient has a disease like gingivitis, we should be educating the patient about why they no longer qualify for a regular cleaning, showing them things like the bleeding sites, the red margins and, most importantly, the fact that gingivitis is reversible. I think that having a strong recal protocol for your gingivitis patients, such as bringing them in more frequently and adding services like laser bacterial reduction, will not only improve non-surgical perioprocedure performance, but it's also going to increase production and collections, which means this is a win win, win. Win for the patient, because we are not documenting a bloody bit prophy, we're treating disease. Win for the providers, because we are now increasing office collections when we bill for benefit because we're thinking about how we're losing money on this visit, we all lose in the end. We want to make sure that we have an established re-care system for our gingivitis patients. We want to make sure that we have established decision-making tracks that we all stick to. We understand what a healthy prophy patient looks like, what a gingivitis patient looks like and what a periopatient looks like. It is very important that we establish how many times the gingivitis patient is going to come back, what services we're going to include, such as the LBR. What does the patient's benefits look like in terms of insurance reimbursement. How is this going to help the patient and explain to the patient how we are trying to reverse the signs and symptoms of gingivitis, because the next step is moving into an irreversible disease called perio. Most of the patient's home care is going to help us reverse the signs and symptoms of gingivitis.

Speaker 1:

I know all of this because I have surveyed and worked with hundreds of dental hygienists and I have asked them candidly when you have a patient who does not have periodontal disease but you are going sub-gingival on a cleaning and there is some bleeding present in more than 30% of the mouth, would you say that you still document for a bloody prophy and friends? I would say there's a 50-50 split there. 50% of the hygienists are adequately documenting for a gingivitis cleaning and the other 50% had no idea that this code even existed. Happy about it because it more accurately describes what we are actually doing during that hygiene visit, but also kind of scared them because now they're thinking okay, well, I have been seeing my patients for five years Now. I realize I have been doing some gingivitis cleanings, documenting and informing the patient that they can come back in six months for a regular cleaning and, gulp, I need to now talk to the patient about a gingivitis cleaning and the fact that they have gingivitis, which is a reversible disease, but it is still active disease. So I think part of the challenge here is that we have to learn how to have this conversation with our patients right.

Speaker 1:

For all of the procedures that we are billing for benefit. Do you think that we're doing that because it just makes it easier. We don't have to talk to the patient about any out-of-pocket expenses because we're just going to bill for the benefit and let the rest go. Why is it that we accept this indentistry? We indentistry need to get better at explaining the patient's benefits so that they appreciate what our doctors and our hygienists are doing. They're treating active decay, they're treating active bacteria, active infection under the gum line. These are serious things that our providers, our doctors, our hygienists are treating on a daily basis. That is impacting our patients' overall health, yet we don't emphasize that to our patients, we don't reflect that in our billing practices and, most importantly, we're not collecting for it, which is impacting our bottom line. That's why I said earlier, billing for benefit is hurting your bottom lines.

Speaker 1:

Let's go back to this example. Your gingivitis cleaning pays less than a prophy, as the example with my doctors in Virginia, delta Dental pays D4346 less than a prophy. The benefit is now billing for a prophy. However, if we were to pair that gingivitis cleaning with a couple of things, we could turn this whole scenario around. If we were to add laser bacterial reduction LBR to the gingivitis cleaning, we're going to add some production and collections and typically what I see most offices will bring the patient in for a minimum of three visits over the next 12 months. So now we're adding another visit.

Speaker 1:

From a bigger picture standpoint, yes, if we only do a gingivitis cleaning in one visit, with no additional benefit of laser treatment, and we don't bring the patient in for additional cleanings, the point is to reverse the disease. If we're looking at it from just this visit, we are definitely being cheated by the insurance companies. But does that justify committing fraud? Because that's exactly what it is. It's called healthcare fraud. You must document and bill for what you do and, friends, there are many ways we can bill compliantly with all of the services that I just mentioned and profitably.

Speaker 1:

But we have to be willing to do better, both clinically and administratively. On the administration side, we have to understand how to anticipate patient co-pays if, in the event, we have a scheduled pro-fee patient coming in for a regularly scheduled cleaning and now we have to have a conversation with the patient, informing the patient that they have a disease called gingivitis and what gingivitis is and how their insurance is going to help them with their re-care, also explaining that we're gonna need their help to reverse the disease. The help is gonna look like them coming in for more frequent cleanings and adding a laser therapy during those cleanings. So I know I called this frog number one because, as you can see, the pro-fee benefit when you are doing a gingivitis cleaning is a big deal. Not to mention, I used an example of an insurance company that pays less for a gingivitis cleaning than a pro-fee. However, with most insurance companies, that's not gonna be the case. With most insurance companies, you're gonna find that the gingivitis cleaning on average is anywhere from, I'd say, $80 to could be up to $150 more than a pro-fee visit. So we definitely wanna make sure that we are documenting all of the critical components that go into billing for a gingivitis cleaning. I think that if we can modify billing for benefit and understand how to present the things we are actually doing to the patient with regards to how their insurance is going to pay or not pay, we will see an improvement with collections. We will have happier patients.

Speaker 1:

If you look at Google reviews, you'll see that most of the reviews are because the patients no, the patients don't understand their benefits and they feel like they were baited and switched. When you look at Google reviews for various dental practices, you'll notice that they revolve around patients not understanding why they were charged what they were charged, especially when there's a surprise balance. And surprise balances cause anxiety for both sides for the dental practice and for the patient because A the dental practice now has to go back and say, hey, your insurance did not pay what we anticipated, which throws the patient into a defensive mode. And what do we normally hear in some cases? That's your problem, that's not my problem, I'm not paying that. And that puts the doctor in a really bad position, because doctors do not want to lose their patients, they don't want their patients upset. So sadly, a lot of dentists are just gonna write that surprise balance off. This can all be avoided.

Speaker 1:

That's another silent threat that we'll get into in another episode, which is talking about surprise balances and how we can avoid them. However, in this episode One, this is one of the biggest frogs within the box of silent threats in our billing arenas, which is billing for benefit because we're not having the right conversations with our patients. And I know a lot of you are going to say, yeah, yeah, erica, but it's just easier to bill for that FMX or it's easier to bill for four bite wings and one PA, as long as I say a certain dollar amount below the FMX, I'm not going to get the denial of an FMX. Friends, we have to do better. We have to learn how to present things to our patients, how A how to explain benefits, not bill to the benefit. We have to have the patient pay for the services that they're actually having done, and when we bill to benefit we remove our ability to have that conversation with the patient. So no more billing for profies when we're doing periomainence. No more billing for profies when we're doing gingivitis cleanings. No more billing for Pano, I'm sorry. No more billing for FMX when we do a Pano and four bite wings. We want to make sure that we are billing for what we're actually doing.

Speaker 1:

Before I sign off, I want to talk about one more area, a silent threat in our billing arena, and that's going to be your fee schedule management. If you find that you do not have a fee for 4346 because you've never used it, reach out to me and I will look up the fee for your zip code so that you can start implementing 4346. Now you have no excuse. I don't want you guessing. I want you to have a solid foundation in implementing D4346, your gingivitis cleaning. I also want you to think about the last time you increased your UCR fees or you increased your contracted rates.

Speaker 1:

I have an invaluable resource and a trusted PPO negotiations company that I work with and refer my clients to. If you're interested in that recommendation, I'm going to put a link to the company in my show notes. I want to give you food for thought, because that is another area that is a silent threat when we are talking about our box of frogs and all of the threats that we want to get rid of as we close out. I want you to go eat that frog and start thinking through how you are going to stop billing for benefit and start having the right conversations with your patients so that you can continue to thrive and we can increase collections. Okay, my friend, if you have any questions about anything we talked about, I am here for you. Go to the link in my show notes. My contact information is there and I would love to continue this conversation in a phone call or a Zoom meeting. And until the next episode, go eat that frog.

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Ericka Aguilar

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