The Dental Billing Podcast

Mastering Dental Claim Appeals with Tessina Bullock

• Ericka Aguilar • Season 8 • Episode 2

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As I sat down with Tessina Bullock, the powerhouse behind Veris Insurance Verification, a tale of transformation unfolded. From her early days as a dental assistant to her ascension as a dental billing mogul, Tessina's trajectory is a masterclass in leveraging communication prowess and strategic acumen to navigate the complexities of dental insurance verification and appeals. Her insights illuminate the path for dental practitioners to not only submit claims with confidence but to also stand their ground against daunting insurance denials.

In the heart of our discussion, the significance of networking came alive through Tessina's entrepreneurial journey, proving instrumental in the birth and blossoming of Veris. As we peeled back layers of insurance verification challenges, Tessina unfurled a blueprint for preempting claim denials with comprehensive patient information—a leap toward fortifying a dental practice's revenue cycle. Tessina's narrative is a testament to the power of connections and a thorough approach to insurance verification, serving as a beacon for those in the dental arena.

Rounding out our candid conversation, we mapped the battleground of insurance claims and appeals, where Tessina shared her tactics for compelling insurance companies to honor their obligations. From the art of crafting personalized appeals to using strategic keywords and the threat of escalating issues to higher authorities, Tessana equipped listeners with an arsenal to combat insurance company tactics. Her guidance is a clarion call to dental offices, championing the notion that with the right strategies, appealing insurance denials can shift from a daunting chore to a winning endeavor.

To get in touch with Tessina:

https://verusdental.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:

Friends, before we dive into this week's episode with my guest, tess and a Bullock, an appeal queen, I want you to prepare your heart because she is going to drop some serious knowledge on inside workings of insurance companies and the appeal process how to win. I have to admit I like her method better than mine, so I'm going to ask you to have a pen and paper ready because she's going to walk you through, step by step, how she wins 100% of her appeals. Now on with the show. Tess and a Bullock, welcome to the Dental Billing Podcast. It's such a pleasure to have you here.

Speaker 1:

I have been excited to do this interview because I just recently learned about your appeal process and we're going to talk about that in today's episode. Before we do that, I just wanted to introduce you to my audience. You are the president of Veris Insurance Verification and you guys do verification for offices all over the country and you have a very simple process. You make it very easy for your clients and I can appreciate that. Can you walk us through your journey in dentistry? Talk to us about how it started, how it's going and all the things? How did you become a dental preneuer?

Speaker 2:

Yes, well, thank you so much for having me. I'm so excited for this opportunity and I've been loving just getting to know you and everything that you do, so this is an honor for me, so thank you for having me. Where did I start in dentistry? I mean, this could be a long story, that's okay.

Speaker 1:

That's okay, and if the listeners could have been a fly on the wall before we actually hit record. Tess and I have been talking about all things dental for at least what we started at my time, and it's 1003.

Speaker 2:

So we got carried away. We did. So, yeah, I got started in dentistry, probably back in like 2007 or eight, and I was a single mom at the time. I had a little girl. I had just become a single mom and I was like how am I gonna take care of her? And I was waiting tables and working all of the late nights, weekends and everything, and I was making fine money with tips, but I just never got to see my daughter.

Speaker 2:

So I was like what career, what can I go into, what can I do? That has like no nights, no weekends, no holidays. And I'm out here in Utah and dentistry just marked all of those points. In Utah and not always for all States, but in Utah they don't work late nights and holidays. So I just that's how I started and I went to school to be a dental assistant, started in dental assisting.

Speaker 2:

Quick backstory my father he's a huge entrepreneur. He would rescue failing businesses of all sorts and was very high stress, managed a lot of things. And I would watch him and I'd be like I am never gonna do that. I am never gonna do that. He is so busy and it's so much and I just like wanna go to work, do my job, go home, have fun, like I'll never do that step.

Speaker 2:

So I was starting out in dental assisting and back then especially, it was a little bit more flooded, really hard to get your skills trained, and so I didn't do a ton hands on because the offices had that. But what they were short in was front office and so they were like, okay, we're gonna kind of train you in both, we'll let you get some of your skills down, but help us out up front. My father had taught me my whole life how to communicate with people, how to profile people side story he's also in the CIA, or was in the CIA, right? So profiling people and how to communicate with people was something that I had just been learning my whole life. So they put me up front and I was more successful than they had ever imagined me being and more successful than I had intended to be. You know, right, and side note.

Speaker 1:

I just want to interject there because people skills matter yeah, they do A ton. People skills matter, and we have a lot of individuals in the front that need better people skills, and I think that dental business owners need to understand that you've got to have your people in the right seat.

Speaker 2:

Yes, and I've done that a lot in consulting where I've gone in and have restructured who they have where, because sometimes they have the gal up front that doesn't want to talk to people, doesn't want to have anything to do with people, and then the girl that is really good with people back doing insurance verification and I'm like wopsy.

Speaker 1:

Which, exactly exactly? And it's not. I'm not knocking anybody that is introverted and it takes more energy to interact with people because it does right Sometimes. For me it's very easy. Public speaking comes very easy. For me. It doesn't stress me out, but for other people it would. Now, if you put me in front of a computer all day, it's going to stress me out. I have to interact with people and vice versa. There are individuals. So please, to those of you that are listening to this, I am not knocking anybody that is an introvert. I'm just saying sometimes we put our people in the wrong seat, yeah, and there's nothing wrong with it.

Speaker 2:

But they're not comfortable in that position either. They would be happier being in a different position. So give them that opportunity to find out where they shine and what they're comfortable with, because they're going to be super stellar in the computer stuff or in these other aspects there's. Everybody has their unique gifts and talents. Find out what they are and use those right. Tap into it. Tap into that.

Speaker 1:

Tap into that, like Tessana and I. I mean, we're like tangent city, so we will go off. So okay, going back to your journey in dentistry. Now you're working in the front office. You're super successful. Now I'm working in the front super successful.

Speaker 2:

They bumped me up to like an assistant manager and then I leave that practice and I go and become a full manager at another practice. And being the full manager at this practice, coming into it, things were a mess. Their AR was a mess, their insurance was a mess, like there were so many things and I just wanted to fix it all and getting into the insurance. Nobody trains you for this, nobody teaches you for this. Sometimes it's what somebody else says and I was calling insurance companies and fighting some of these claims and these way old claims that have not been paid in forever, and all these things and the insurance company kept saying to me like this is how it's done and we have the control and you have no control and I don't deal well with that.

Speaker 1:

And she is a disruptor, let me just say Disruptor.

Speaker 2:

And I'm sorry, and again I Sorry, not sorry, sorry, not sorry, but again, I was taught and raised and trained that we have rights, we have protection, we have Like you know, and like I'm the boss, yes, yes, and so I'm like. Says who, and they're like. Says me, I'm like, but says who, like? Who says to you that you're in charge and who says to you that you can take this from my patient and tell my patient that they have to pay when they're paying you a premium? I'm like, is it a covered service? Is it this? Is it that? So I just started getting really overly like, aggressive towards the insurance companies, noticing that they were these huge bullies and they were just bullying the heck out of all my patients who I dearly loved and had gotten really close relationships with. And then these insurance companies are just bullying them and I didn't like it. And who's going to protect them? I decided I was going to protect them. I don't know.

Speaker 1:

I love that. I love that and I want to pause there because I kind of want the audience to anticipate your process, because you have a very unique process to the appeal actually to the appeal process and very different from mine. And I love when I learn new things from other billers in the industry and I truly believe that your process is way better than mine because it's quicker, it's faster, it yields a result a lot faster. So I'm really really happy that we can share your process. But before we get into that, I want to go back to how you became your office manager. Now, so fast forward. Now you are a dental business owner, you're a dentalpreneur. So you went. You're like me. We started as dental assistants and now we're dentalpreneurs. So talk to the individuals who are one day hoping to have their own dental business. Other people like us that started as dental assistants and now we've moved into an entrepreneurial space. Talk to us about that and then we're going to get into that lovely process that you have?

Speaker 2:

Yes, yes, yeah. So definitely, when I was learning some of these things that I was learning, I went through to find out all the laws, all the legalities and all these little things and I thought there was so much more that I didn't know. So my journey started out. Just wanting to learn, wanting to know, I thought I was behind where everybody else was, and I started joining study clubs or finding friends and finding groups and there's this big like oh, you can't talk to the other office's office manager. And I don't know why I didn't like that. I was like why would we not talk?

Speaker 1:

There are so many comments like these preconceived notions or these misconceptions in dentistry. I don't know why we create these barriers within our communities, but we do.

Speaker 2:

We do and it was really bad back then. I think it's gotten a lot better now. You can see there's all these Facebook groups and people are talking and coming together and that's how we learn and that's how we grow. Back in the day because I'm a little red, but back in the day that wasn't a thing. You weren't talking to each other.

Speaker 2:

And so I found this group of gals. That was amazing and they were doing a study group and they let me they were so nice to let me join in with them on their board or whatever. So we would host the study clubs together and invite everybody in and they'd be open communications. And I quickly started finding out that I wasn't actually as behind as I thought I was. I was actually ahead in my efforts to hurry and catch up and learn as much as I could and go do this extra research and what are my laws, what are my rights, what? Who do I battle all of these things and I go to the study clubs and nobody else knew any of that stuff. So yeah, so I just started sharing it in study club settings.

Speaker 2:

We started doing seminars and inviting people to come to our study clubs and started meeting all of these other people in the dentalpreneur world and networking with them and getting those opportunities where all of a sudden, they would connect with me and be like you should join in on this.

Speaker 2:

You should be doing this and what's the title of your seminar? Our little group was the UDALS study club, but UDALS it was like Utah dental, yeah, udals, and we had our little study club and there's ADOM, you know. So we had actually gone as far as becoming an official Utah chapter of ADOM. It was tons of fun and so they gave us some support. We went out to the Utah Dental Convention so they have their conventions every year and we would go with Patterson and we'd have our own little booth and sign up people to come out to the study clubs so that we could share information together. So it just started with all that networking of getting to know all these higher up people, all these people who are already doing it, and they were so welcoming and so, like you and I are saying, let's say to these other people, like we are not in competition with each other.

Speaker 2:

We are all here to help each other, right? So they were like come join me on this project, or you should help with this project, and I have a client for you over here, and it just spiraled out of control.

Speaker 1:

I think the takeaway and this part of your journey, for those in the audience that are listening is networking is key for anybody that is looking to start a business, whether it is a dental practice, whether it's a dental billing business. I heard this today. I follow a few entrepreneurs, podcasters, and one that I am huge. I listened to the Jasmine Star Show. I love Jasmine and today, just this morning, she said you are one ask away from everything you want. She was referring to network.

Speaker 2:

Yeah.

Speaker 1:

It is so true it is. I have a story behind that that I won't share now, but it is so true. So I think the takeaway here is networking is key.

Speaker 2:

Yeah, definitely, and so it just started spiraling and I didn't do insurance verification where I did all this other consulting. But as you know, erica, it always goes back to like what breakdown are you getting? That's like the starting point. And Ben Tune right, he reaches out and he's like he always. He was one of these great networking colleagues We've worked on so much together and he has his own nationwide company. He is getting his clients all the time and when they ask questions to him about consulting or issues that they're running into with their office, claim-wise that he doesn't do because he does the P negotiations, he would reach out to me and we'd go back and forth. And then he said why not do an insurance verification company?

Speaker 1:

Right, and that is typical Ben, right, like we know Ben. So typical Ben. He is a serial entrepreneur. Yes, he has a company called Veritas and they are a PPO negotiation company, and I have worked with many of his clients, in fact, with my company, hidden Dental Profit, and his company. With what we do and what he does, we have cross paths with many mutual clients. Yeah, it's just been interesting, but you and Ben now have Veris, yes, and that is the insurance verification company. So talk to us a little bit about what you guys do and how you serve your clients there.

Speaker 2:

Yeah, it's super fun. Insurance verification seems like it could be the easiest thing to do, but we all know, it's not, it's not, it's not the easiest thing to do.

Speaker 2:

It is the most annoying thing to do. So most offices, even if they have a good breakdown form, what I find and you might find the same thing is that they're not actually filling it out in its entirety. So even if they have a great form, they're calling and they're in a hurry, they have a patient waiting, they have the phone ringing and they have to get this, so they default down to just the few basics that they absolutely have to have to get that patient going and they don't fill out all of the extra questions. Even if they have a great form, Normally I find that their form is missing questions. But even if they have a great form and I go look through a couple that they've done they're not filled out in their entirety. And the common thing is I just don't have time. I had to wait on hold for an hour or I can't get the website to work.

Speaker 2:

All of those things and sometimes that information. There's some information for insurance companies that is global-wise, right, Like Delta Dental. You don't have to ask or call or go to the website. You just know that all Delta Dental plans for SRP are only two quads per day of service. That's not all four quads same day. So those things like those global rules, I have this masterful document.

Speaker 2:

Yes, I have all of the insurance companies and all of their little global rules and things that I know across the board for that company. That's what they follow. So I have that document that I had created for me and that was your verification team. Yeah, so they use that. Yeah, so offices again, they just don't have time, Like, even if they know or they kind of remember, sometimes those details get mixed up as to which company was which because they don't actually have the documents to it or the proper updated references and they don't have the time to go through that. So we train the verifiers on all those expert tips and of what those global notes are, how to properly utilize the websites to find the additional information that's hidden and what specific questions to ask the representatives. If you have to call in All of those expert tips into verification and then they can get your whole form filled out, they're asking all of those extra questions and they're still doing it in a really fast time for a really low cost.

Speaker 1:

I mean talk to the audience. I think that you're very affordable and it's a very thorough breakdown. Talk to them a little bit more about what is the fee for insurance verification with your company.

Speaker 2:

Yeah, it is $15 an hour.

Speaker 1:

So one of the things I wanted to point out as I look at billing departments and I do take a look at the breakdown, which is why you and I connect we believe that the revenue cycle is kicked off with a really good breakdown. When I look at the breakdowns, I always I see that we get history or frequency and no history. Yeah, I see that so often, where I understand what you mean when you say sometimes they just pick and choose what they're going to get. I always tell my students or people that I'm training frequency and history are sisters and they don't go anywhere without each other. If you're asking for frequency, you need to get history. I mean, there's just no way around it. Yeah, do you find that to be a common challenge or something?

Speaker 2:

Definitely.

Speaker 1:

When a claim is denied due to frequency. There's nothing that drives me crazier than that we didn't take the time to properly inform the patient of their cost, Definitely.

Speaker 2:

I had a client in California yesterday email me and say that they had submitted some services for a patient and then it came back saying they were maxed out. And they didn't know that that patient was maxed out, but they didn't ask. So I go back to that basic training of like did we ask about that on the entrance breakdown form? And they're like how do we? That was so simple, Such a simple thing.

Speaker 2:

Now that patient is frustrated and upset at you, whereas initially you would have been like you're maxed out, you're going to pay full fee. Here's how much that fee is. And they accept it and they pay you, Instead of the fight backwards of like, yeah, your insurance is maxed out and you would have paid this either way. You just didn't know that ahead of time. So preparing them ahead of time is everything. They will accept the treatment, they're happy to do the treatment, they're happy to pay for that treatment. They just need to know ahead of time, they need to be able to plan and budget and all of those things. So having the breakdown and having those good estimates are so so important.

Speaker 1:

Chart preparation is everything. I think I did an episode on that and it was called Chart Prep. I did a whole episode on how important it is to be prepared for the patient's visit because it plays into their experience and their experience leads to good or bad reviews on Google and a lot of those reviews are driven from finances right and definitely prepared that we are Like 90%.

Speaker 1:

I know there's a. That's actual statistic, right. Yeah, yeah. So it is amazing. Okay, we have teased the audience with your appeal process, so talk to me a little bit about your appeal process. So you get a denial for, let's say, a buildup, because that's the common theme in all of these groups. So common.

Speaker 1:

So common. So let's talk about your appeal process when a buildup is denied or they want to incorporate the buildup into the feet of the crown. Walk us through your process, because I know you have mentioned to me several times you're not nice, I'm not nice. You're not nice and you actually say you're mean, I mean I'm not nice.

Speaker 2:

I'm the boss when I work with other offices. They are basically begging and pleading with the insurance company to please cover these services. So they will give, give, give documentation and say please look, this really needed to be done. Can you please cover this? I am like, if you don't cover it, I will report you and I will take you down.

Speaker 1:

Love it. I absolutely love it. Ok, so talk to us about how you take them down, how I take them down.

Speaker 2:

So yes, with the buildups and all of those things, my first process is actually making sure that that initial claim is sent out correctly. If I have all my T's crossed and my I's dotted right, it's so easy. My appeal process is no. I already gave you everything that you need to process this claim in good faith by law that they are required to do. I'm not providing any more documentation and if you don't have this paid, then I will report you and they pay it, or if they don't. So I talk about this.

Speaker 2:

A lot insurance companies. I have a. I make a lot of friends on the inside of these insurance companies and they I can never name them right they still are inside these insurance companies and hire up insurance companies, slag offices. This is like my biggest secret. They flag offices as to whether or not you can be bullied or whether or not you're not to mess with. So I tell offices be a whistleblower. So the way that these insurance companies, all of them are doing it, it's all standard protocol to deny claims, delay claims, delete claims, all of those things. They will continue to do it as long as they don't get caught. So if you are whistleblowing them, they will more than happily flag you as an office to leave alone so that you don't report them and they can continue to do it to millions of other offices and just leave your office out.

Speaker 1:

Okay, so let's like park for a second. And then I just want to reiterate that, because I have said that in the past and I have said AI is real and insurance companies are monitoring the offices that send appeals in. Whether you use my method or you use Tessina's method. They are monitoring whether or not you are appealing and the offices that appeal more often are left alone, and I have said this before, so I'm so happy that you're reiterating that. And then walk us through a little bit more about how you know this. I know you've had the conversations with the consultants, but talk to us a little bit more about how you came about all of this knowledge.

Speaker 2:

Yeah, definitely, like I said, I like to make a lot of friends and I like to not be left unknown. So I'm and I told dental dentists specifically that if their staff is on the phone with an insurance company and they're getting kind of chatty, I'm like don't tell them not to do that. That's literally how I made all of my inside contacts.

Speaker 1:

Oh my gosh. I have a list of people on the inside Every insurance company. Since I was a dental administrator, I have a list. Now a lot of those people are gone because of COVID and everything. But then you make new friends.

Speaker 2:

And you'll say like who took your spot? And they'll sometimes, if they leave, they'll dish more secrets to you than they could when they were in. So I actually love it when one leaves once in a while because I'm like, hey, now tell me you know. But yeah, so talking with the dental consultants that do the reviews of your claims I've made many friends with them and have talked with them at length they will tell you that they are not given everything that you submit. They're only given portions.

Speaker 2:

And those digital X-rays the insurance company prints them off and mails them over or faxes them over. So when you get that denial saying that that X-ray isn't readable, it's not because you did anything wrong. The insurance company intentionally printed that and mailed it to the consultant. And the consultant is saying to the insurance company I can't read. This dentist consultant is not even necessarily telling them to deny the claim. He's reporting back to the company that he can't read those X-rays. And that insurance company is like, sends us the denial saying, oh, they can't read the X-rays, you have to send an X-ray. But we already know we sent a good digital X-ray and they're just playing games. I don't send them a new X-ray, especially if I go and look at what I sent and it was good. I know they're playing games and I give them one opportunity to clean up their act before I report them.

Speaker 1:

Yesterday we talked about this and I had called you because I said what do you do about your narratives and we can talk a little bit more about this after the appeal process. But that's how we kicked off the conversation and somehow it turned into appeals. I think we talked about it, we're going to talk about it on the podcast, and you had mentioned that insurance companies are deleting claims, they are deleting attachments, and is that being done intentionally or is that 100%, 100%, okay, so talk to us a little bit about that. So again.

Speaker 2:

It's just about the fact that they do this, a standard protocol in efforts to delay the claim or intentionally deny the claim. They do this so to better their numbers, right, that makes sense. And it makes sense and they do it to better their numbers If they paid every single claim right away, as soon as it came in, and even if they know they're going to pay it, but they want to pay it in 30 days instead of today, they have all of these tactics because that's the only way it actually produces more revenue for them. So, aside from raising premiums on patients which they will do with no problem but they really don't want to do that too much because they worry about losing their clients. So more on, the better end is to get as many clients as they can, keep that premium reasonable and then delay, deny claims. That's how they get their money. That's how the game is played, and as long as they can get away with it, they can continue to do it.

Speaker 2:

Even filing an appeal does let them know that you know, hey, you're not doing this right. And if they pay that appeal, you have no reason to report them. So they are very likely to pay your appeal, even if your appeal isn't super fancy or anything, just you sending that appeal saying something's wrong here. You should have paid this. They will usually get that pay because the next step from that would be filing complaints. There's this attention on them now and of what they know that they are illegally doing, and they don't want that attention brought to them. So filing that appeal is the first step. The interest commissioner will ask you to file an appeal, always before you send it to them, because you have to show proof that you did try to work it out with them first.

Speaker 2:

So again, I think we were I'm kind of back and forth, but talking about how we know what's right for them to do, what's not right to do. I had lengthy discussions with the insurance commissioner, with the federal departments, as to what the laws are, what are our rights, what are our laws? What is the insurance company allowed to do? What are they not allowed to do? What are we allowed to do, what are we not allowed to do? So when I battle it, I'm battling it very confidently, knowing that they are not allowed to do that and also knowing, because I have those inside contacts, that they are doing that right. So deep.

Speaker 1:

Oh my gosh, let's pause there. So, knowing that what our rights are, yet knowing what they're also the shenanigans they're playing on the inside. And so when you talk about laws, like you're talking about state laws and federal and federal and federal federal, universal with regards to the insurance, commissioner, and does that apply to self funded plans as well?

Speaker 2:

So the insurance commissioner doesn't necessarily follow the federal laws. They have their own state laws but they do notice and recognize those federal laws and try to apply them as much as possible. Self funded plans are federal plans, so the insurance, the state insurance commissioner does not have jurisdiction over them. Yes, We've talked about this before. When you submit a complaint to the insurance commissioner, If you tell them right off the bat that it's self-funded, they will reject it and say we have no jurisdiction. But what I do? Tell us everything. You guys, you know I'm not very nice.

Speaker 1:

I said she's a disruptor and I meant it.

Speaker 2:

I'm a disruptor. I don't tell them it's a self-funded plan. Since I didn't give them that information, they send it. So the insurance companies have this specific high-up department that handles these complaints. Their job is to get these complaints resolved as quick as possible. So they're not in trouble. Since I don't disclose that it's a self-funded plan, they send it to that contact at that insurance company and that contact looks at it and says oh no, we've been flagged, let me go look. Oh, it's a self-funded plan. Then replies back and says you don't have jurisdiction, it's a self-funded plan. I get a response from the insurance commissioner saying this is a self-funded plan, I have no jurisdiction. Here's the number to contact for the federal department to file the complaint with them. Now I've done two things. I have already notified that high-up contact who is in their nature. Their whole job is to hurry and get these disputes.

Speaker 1:

The whole purpose in life, while they are on the clock, is to resolve these complaints.

Speaker 2:

I've got their attention on it. Now they get a copy from that insurance commissioner the same copy that I get that says here's the number to go complain to the federal department. That contact doesn't want me to follow that next step. I don't call the federal department right away. I wait two weeks and I usually have my payment.

Speaker 1:

This is all the things that we need to know to just cut to the chase, like we don't care if you're self-funded or not, we're just going to follow this process. Now that we know, you have all the tricks up your sleeve and you've just shared them. I know that you did an article in Dental Economics on this topic. It says you had a huge response. Walk us through, if you can. I want my listeners to pay attention. You guys need to get a pen and paper out because she's about to tell you, step by step, how to do this. Tess, if you could just walk us through, I get a denial. Walk me through step by step what I?

Speaker 1:

need to do up to filing a federal complaint.

Speaker 2:

Yeah, definitely If I get that denial and if it's me that had originally sent a claim. I know I had all my T's crossed, my eyes dotted, so it's pretty easy. But I usually tell people go and double check, especially if you have different people in the office submitting claims. Go and check and make sure that you did have the proper documentation going out on that initial claim. If that initial claim really didn't have that documentation, you can go ahead and provide that documentation by law. You do have to show some proof of validity that that service needed to be done. The insurance companies are allotted that law to protect from dental offices taking advantage and just submitting claims for stuff that didn't really need to be done. They are allotted that that we have to show some proof that it really did need to be done. If that was missing on the initial claim, go ahead and send that with a warning that hey, I'm sorry my initial claim was missing. That here it is. Now you have everything that you need, process the claim and I always tell or I report you.

Speaker 1:

So you actually put that in the remarks section. Yep, really Definitely. Here is the missing information and now you have everything you need to process this claim.

Speaker 2:

I don't say please process. I say process immediately for correct payment, or I will file a report with the insurance commissioner. Very cool yeah. Then if my denial comes in and I was successful in submitting the claim correctly, nothing is missing my response to them and it's not always an appeal. So I'll say this sometimes because they're saying they need more information and appeal is not necessarily the correct route. So if it's a flat denial and you have to appeal it, make sure you're following the correct appeals process and then the wording is going to be the same. The wording whether you're doing an appeal or giving them the additional information they're asking for. That's going to be the same. But make sure you know if you're doing an appeal or just say that you're appealing it.

Speaker 2:

Yes, that's what I'm saying. So if they're saying they need an appeal, make sure you're following the correct appeals process.

Speaker 2:

If they're not saying they need an appeal and they just need additional information or they're missing information. You don't technically have to have an appeal, you can just provide additional information or dispute that with them. So make sure you know which process you're following there. But either way, the dispute is not. Here's a whole bunch more x-rays and an intraoral image and the clinical notes from the doctor, and please pay this. Your response is no. I already gave you everything that you need that shows proof of a clean, valid claim. I showed enough evidence. It's a sufficient evidence. Is the wording. So I already showed sufficient evidence. That's the legal verbiage of the treatment needing to be done. You have everything that you need. This is a clean, valid claim Processes for payment.

Speaker 2:

Clean valid claim. I love that Clean valid claim and if you don't process this immediately, I will file a complaint with the insurance commissioner.

Speaker 1:

That's my response. And so, with that response, what is your turn around time like when you? How often does this actually have to get taken to the higher level? Yeah, do you find that at this point they will just pay it, or what do you think? The percentages before you actually?

Speaker 2:

Some will, yeah. So I will say, I will say this because they're flagging you in the beginning, you're going to have more denials than acceptance. Right, they're going to be testing you. They want to call your brother. Do you know how many offices say and threaten like I'm going to file a complaint and never do a lot, right? So if this is your first time doing it, I would expect it to not be super successful, and that's okay. What you're going to do is, if they don't pay it, you're going to go ahead and file that complaint with the insurance commissioner.

Speaker 2:

After doing one of those for each insurance company that is trying to push you around, they will flag you and they will say okay, this office figured us out, they're a whistleblower, we need to back off.

Speaker 2:

So if here's how the legal part, or the part that the insurance commissioner does with them If they pay the claim once we submit that complaint, there is no negative action taken on the insurance company because they have not been proven to do anything wrong, they can say it was an error, it was a glitch, it got slipped through the cracks, we've corrected it. There were not at fault for anything, right? Okay, and that's what they want. That's what they want. So if they pay your claim when you file the complaint with the insurance commissioner, they're not in any trouble with the insurance commissioner. The insurance commissioner is aware of them, might be watching them, but they're not in any trouble as long as they pay it. So they're pretty much wanting to pay that. They're not wanting to get too many eyes. If the insurance company has multiple complaints from multiple offices or even from the same office, they can do an investigation and they can find the insurance company if they suspect that they are intentionally doing this on a large amount of claims right Across the board.

Speaker 1:

Right, and they are. What I wanted to interject here is because I think this goes right in alignment with what you're talking about. I always encourage offices to monitor their denial patterns and keep those on file by insurance company. You're starting to see a lot of denials for buildup with SIGNA, which I think SIGNA and Guardian are the biggies right now. Keep those on file, but also make sure that you are appealing all of those I told you yesterday. I have billers that I have conversations with who have literally given up on billing buildup at all, because I look at the utilization patterns within their coding profile and I'll say okay, I see that you did 650 crowns over the last 12 months, but I see no buildups. Are you guys not doing buildup or what's going on there? Well, we stopped billing buildup because they don't get paid.

Speaker 2:

So I have something to add to that. Insurance companies decide what codes are covered by the utilization. If you're not billing it, they will say it doesn't need to be covered. The biggest mistake offices make is not billing it because they think it's not covered. That you're actually telling the insurance companies to continue not covering that service ever.

Speaker 1:

So the more you. We're not talking about a fluoride that's not covered due to age limitation, right?

Speaker 2:

Speaking of fluoride, back in the day it didn't used to be covered, even for children. For some of those that have been in the field for a really long time, we know that fluoride was never covered. And now we're seeing it covered on children, and that age limit has been going up and up and up, and the reason being is because more and more offices are submitting the fluoride treatment even though it's denied for the age limitation, the insurance companies starting to see these patterns and starting to see the need for it to be covered or covered at a higher age.

Speaker 1:

And I think we just did a webinar together, what was about two weeks ago, and it was the insurance untangled webinar. I believe it was Jordan's mom that asked why do insurance companies not increase maximums? And Bollin had answers. My answer was about 7% of people that have PPO benefits use them. Only 7% of the population with PPO benefits actually use their benefits, and I learned this from Dr Roy Shelvern. He and I did a workshop together at the beginning of the year. Then you also had something to add to that. What was your answer to that?

Speaker 2:

So they're not. The offices aren't submitting their office fee. That's the problem. A big part of the problem. It's both, but they're not submitting the office fee. So if you're saying a crown is only $500, a filling is only $80, they're saying our maximum at 1500 is totally fine. A thousand or 1500 is totally fine, it can cover this many services. If we show them that one crown is $1,000 or more, they know that they have to raise that maximum, that they won't be able to get any of their services done. We're just underutilizing. The biggest mistake is they're billing out what their contracted rate is instead of their office fee. So insurance companies aren't aware and they're not billing codes that they think are not covered because they're like what's the point? It's not covered. The point is the insurance company needs to know these things. They actually do need to see these things.

Speaker 1:

Otherwise they have no idea.

Speaker 2:

We can't always blame them for everything. Some of it's our fault. These guys aren't in dentistry. None of them do dentistry. None of them know anything about that. They're literally going off of patterns and they're watching what's normal, what's acceptable, what's not acceptable, and then they base their coverage off of that. If we're not telling them this is a needed service, if we're not telling them this is how much the service costs, how are they?

Speaker 1:

supposed to know? And yes, and I mean, we've seen that progression with the introduction of new codes. Let's take gingival irrigation For the longest time it didn't even have a code.

Speaker 2:

So we were using.

Speaker 1:

I think it was like D9630. Back in the day we were using that as the irrigation code and then we got the irrigation code and it was not covered by any plan. So now you're seeing reimbursement for that code and I think that's where we need to educate our billers, in helping everybody to understand that the more we educate the insurance companies, the more likely we're going to receive reimbursement at some point. Now it's not going to be the best reimbursement, you guys. It's definitely not going to be. You're not going to jump up for joy, for sure. It's just one of those things that it's a two-way street and I love that you've said it's not always their fault, it's our fault in how we manage our claims, putting our full fee on the claim form and so much that we could definitely expand on. So, with all of that being said, if anybody has any questions about this whole very unique appeal process, I love it. What are some of the keywords, Because you had actually mentioned that previously that they're looking for keywords in a narrative, in an appeal.

Speaker 2:

Talk to us a little bit about that the keywords when you're submitting that initial claim, your narrative we talked a little bit about this. It doesn't have to be a whole page. It doesn't have. Again, we're not begging them to pay the service. We don't even have to explain to them all the details of the service unless okay. So I know, if you do one of those that says unspecified, then you do have to explain what you did. Oh yeah, definitely If it's a crown, we don't have to explain that, right? You know what a crown is. So you're required by law to show sufficient evidence that that needed to be done. This is done in two ways an image and a narrative. So if your image doesn't show clearly why a crown needed to be done, then your narrative would need to state what additional information was missing in that image. So your narrative is getting scanned electronically. They're going to be looking for certain keywords decay, that's like the biggest keyword. They're looking for Decay. Always say decay, decay, decay, unless it didn't.

Speaker 1:

Yeah, I mean as long as there is decay there, I mean come on.

Speaker 2:

Yeah, yeah. As long as there's decay, say decay. If there is decay and fractures, be mindful of which insurance company you're dealing with. Delta Dental has this big deal. They do not do crowns for fractures.

Speaker 2:

Not at all, if they scan the keyword fractures and ignore the decay, you're going to get a denial. So leave fractures off of there, just put the decay. It had enough recurrent decay and then you know that there was also fractures. But I do often try to say if there was decay and fractures I put that. If it was decay and it was broken I put that. So just those very little things. Then, if it's a buildup, they are looking for specifically that it lost more than 50 percent of two structure. So if your initial claim says lost 50 percent of two structure and also that the buildup was required for crown retention, I add that as well that it was required for crown retention. All of my narratives say required. If it's a crown, it's due to decay and broken. Required a crown. That's my narrative.

Speaker 1:

You guys, I look like a bobble head right now because I'm just shaking. I'm shaking my head in agreement with everything Tessana is saying. I just realized I've been bobbing my head the whole time we've been talking.

Speaker 2:

I do that too. I'm like a bobble head over here. Yeah, I do that all the time, so I'm glad I'm not being so much excited.

Speaker 1:

I'm like yes, I know we get so excited. Yesterday I texted you and I was like do you have two minutes to chat? Then I remember when I sent that, I was like it's not going to be two minutes, it's just two minutes. Yeah, you're like I know. Yeah, it turned into like 20. Today we said we're going to do a podcast and we've just gone on so many tangents but such good information, tessana, I definitely want to have you back on the podcast. We can talk about so many other things. You're just like a big wealth of billing knowledge. I love all of the information you just shared with us. It's very informative. Do you believe in using appeal templates? Because I see people that say I have an appeal letter for this, I have an appeal letter for that. Let's talk about that just really quick. Let's talk, finally, about appeal templates, because I am not a fan of using templates with appeals. Talk to me a little bit about how you do that.

Speaker 2:

Yeah, I agree 100 percent. Each situation is a little bit unique. It's really hard to have that template Again. The reason they have this big, huge template is because they're trying to make sure they have all this wording in there. Their appeal is like a whole page long. My appeal is not that long. Right, my appeal is not that long and I don't really need a template. I will usually point out the legal actions that I believe that they are taking and again tell them that I already provided a clean, valid claim with sufficient evidence and that if they don't pay it, I'm going to report them. I don't do a template because I have to go look through my notes and see what it is specifically, what laws that they're breaking. They're not allowed to diagnose treatment. That's illegal. They're not allowed to delay claims for payment by asking for additional X-rays or additional information, assuming you sent everything initially.

Speaker 1:

Yes, you're saying I already sent that to you. I'm not going to buy initial information.

Speaker 2:

They say you give them a bite wing and they're like we want a PA, we need a post-op PA. No, no, no, no, no. We're not asking for tons and tons of information. I already showed sufficient evidence.

Speaker 1:

Sufficient evidence that the procedure was necessary? Yes, and they are obligated by law to pay that claim in good faith, in good faith, they have to take your word for it.

Speaker 2:

So if the X-ray doesn't show but you stayed in your narrative why it needed it, they have to take your word for it now because they required by law to process it in good faith, that you're telling the truth with that sufficient evidence. That's, if they're asking for tons and tons of more documentation or saying they didn't get it, send it again. This is an indication that they are intentionally delaying the claim for payment, which is illegal. So if they're denying a claim for a covered service, saying it didn't need to be done, this is where I say sometimes it can be two it one, they're illegally diagnosing treatment and two, it's actually illegal for them to deny a covered service on a clean, valid claim. So they're illegally denying and illegally diagnosing treatment. Those are the two things my narrative, my appeal, is going to point out. You're illegally diagnosing treatment. You're illegally delaying the claim for payment. If you don't have this process immediately for correct payment, I will report you.

Speaker 1:

Also using those You're saying you're going to report them to the insurance commissioner.

Speaker 2:

Insurance commissioner and I specifically do state the insurance commissioner. Sometimes I'll say insurance commissioner or federal department, whichever applies. So I might say that even, but I do make sure they know that I will file a complaint. That's my next step. A lot of times I'll say this is my final attempt. This is my last attempt to work out. I'll explain Okay, so because they, a lot of insurance companies, will have three levels of appeals. You can do with them. Don't do three levels of appeals. And so if you send one appeal and they think you still have two more, I say clearly this is my final attempt to work it out with you.

Speaker 1:

If you don't have it paid, I will report you that is such gold because I have listeners and I know that we have people who are listening going. I have submitted this appeal like eight times and I came back and forth. So for those of you that have denied claims and you have been going back and forth with the insurance company, don't do that. Send a notice to the insurance company. This is my final attempt before I file a complaint with the insurance commissioner.

Speaker 2:

Yeah, and you're going to get some of those coming back. Initially they might try to call your bluff. That's okay, let them and then show them you weren't bluffing, right. And then they'll start backing off.

Speaker 1:

Okay. So then, to file the complaint with the insurance commissioner is to go to your state insurance commissioner website. So I'm in California, I go to the California insurance commissioner's website.

Speaker 2:

Yes, you can Google it. You can Google insurance commissioner of California and it will pop up with the website. And you just follow the prompts, find the spot that says file a complaint. Right, there's going to be a spot on the website where you can do all these things with your insurance commissioner's department. So you're going to find the spot that's going to say, like I want to file a complaint, and then start following those prompts and it takes five minutes.

Speaker 1:

We're not going to go back and forth with the insurance companies anymore. We are going to give them one opportunity to pay the claim and if they don't, we're not going to do all three levels of the appeal process. We're going to go okay. We gave you a chance. You didn't pay in good faith because we gave you a proper narrative explaining why the treatment was necessary. We even gave you an X-ray showing why it was necessary. And you still have not processed this claim in good faith. I'm going to file a complaint with the insurance commissioner. So then you go to your state's insurance commissioner, file the complaint, and from there, what do we do? We just wait for a response from the insurance commissioner.

Speaker 2:

Yep, the insurance commissioner will call or email you back letting you know that they received that complaint and that they're working on it. Sometimes I'll ask you some additional information of like what have you been saying they? You have a spot to upload all of your documentation. So you want to definitely make sure you upload as much documentation, communications, everything. You sent the insurance all of that over so that they have everything that they need and the insurance company doesn't get a chance to hide it from them. So you want to submit all that. But sometimes I'll ask you some additional questions. Also, side fun note you can.

Speaker 1:

I love it.

Speaker 2:

I don't know. People probably should be seeing now recently Delta Dental is not combining the X-rays with the bite wings anymore. This is because of the insurance commissioner's office in Washington. So all of those providers in Washington were sending complaints about Delta Dental bundling these. So, even though it was in their contract, even though it was not like, you can send a complaint about that and the insurance commissioner will say I can't actually get coverage on that for you because it's in their contract. You agreed to it. But they complained so much and through such a fit that the insurance commissioner went and talked to Delta Dental to say what's going on here? What are you guys doing? This doesn't follow ADA guidelines. This doesn't follow this or that. Delta Dental had to make a change nationwide. Every one of us is benefiting from the providers of Washington complaining against Delta Dental.

Speaker 1:

To the insurance commissioner.

Speaker 2:

Of their state. So, even though it was just of that state, we had nationwide changes for that and we're so grateful. By the way, shout out to anybody who's in Washington.

Speaker 1:

Thank you, aba Washington, in the Washington area, yeah.

Speaker 2:

So file those complaints, let them know, bring it to the attention of the insurance commissioner.

Speaker 1:

So your way of learning all of this is a very unique way and I know it was in an effort to catch up and you thought you were behind and then you realized, oh my gosh, I'm way ahead of most billers that don't understand the appeal process properly. You also took a course and you were given templates and talk to us about this course you took, without naming any names, but you know this course you took. And then that phone call you got from the insurance commissioner.

Speaker 2:

Oh, I was so embarrassed. So again, my learning process. And I don't play the games. Obviously, you guys are seeing that I'm not playing the game. I'm not going back and forth. I want to know my laws and I'm going to hold you to it In finding this out. And I'm trying to go to all these continuing education, all these courses.

Speaker 2:

My doctor paid $1,000. I think it was. This is a long time ago. It still is a lot of money, but $1,000 to go to this course, this seminar, where they were talking to me and teaching me about how to use the insurance commissioner. It was very limited detailed information even in that seminar, but they did provide to us a packet and instructions for how to file a complaint with the insurance cushion. It was this big letter and I think it said you can copy the patient to it. And this letter here was an envelope with an address of where to send it. I was so excited I couldn't wait to use it. I got a denial and I was like I'm going to put these guys into the fire and I'm going to write this paper. Anyways, I mailed it out to my insurance commissioner and they called me and they said what are you doing? Are you trying? Are you trying to submit a complaint Like this? Isn't how you do it at all.

Speaker 1:

I was like I think you're trying to file a complaint, but you are not doing it right.

Speaker 2:

You're failing miserably. Like you're fail. It's not how you do it.

Speaker 1:

I wanted to bring that up because how many billers are using these templates that are being thrown around in these Facebook groups?

Speaker 2:

Be careful.

Speaker 1:

Also, when we use the same template for every appeal, that could also trigger an audit, can also trigger the wrong type of attention. Because, wait a minute, how did the last five SRP denials need the same treatment for the same reason? It looks like the same letter every single time. I'm not a fan of that. I am just not a fan. I am a fan of telling the story uniquely to help the insurance company understand that this treatment was necessary. But I am not going to tell a lengthy story. I, like you, will use key words. Get to the point, Just get to the point. Everything we talked about today it's just like this could have been a whole workshop yeah, Episode by itself. Friends, I hope everybody took notes and didn't go back and listen to this episode again or reach out to Tessana. Her email, her contact information is going to be in the show notes, Tessana. This has been so much fun.

Speaker 2:

Thanks so much this.

Speaker 1:

I'm definitely going to have you back. I don't know, maybe we'll do a series of something or other, but I think, helping my audience to navigate through the appeal process. I want to share a fun statistic with you. In 2017, less than 33% of all denials were ever appealed. Oh my gosh. So the insurance companies are winning, right? Yeah, they're winning because we're not filing complaints.

Speaker 1:

Insurance commissioners are there to help us to advocate for dentists and patients mainly for the patients Like they're not going to do it because they don't know how to do it. And I have hosted workshops all over the country and I will tell you just I have spoken to so many billers who are like well, I don't know how to do the appeal process. Yeah, and it's not because they don't want to, it's because they don't know. So, after listening to this episode, friends, you have the framework to do an appeal, even if you still need to. You know you're going to be like a fish out of water initially, but it'll become more natural and your office will be flagged as a whistleblower, which is what you want you want insurance companies to think of you as a whistleblower.

Speaker 1:

They're not going to give us so many denials. So, Tessana, thank you so much for all of this information.

Speaker 2:

Definitely.

Speaker 1:

I look forward to having you back on the podcast.

Speaker 2:

I'm excited Any time.

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Ericka Aguilar

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