The Dental Billing Podcast

Part 3 Recalibrating Your Hygiene Department with Tessina Bullock and Jennifer Lymann RDH

• Ericka Aguilar • Season 8 • Episode 5

Share episode

Is your hygiene department underperforming when it comes to periodontal care? Join us for an eye-opening episode where we uncover the essential steps to recalibrate your hygiene department for optimal perio performance. We promise you'll learn how to establish consistent perio charting and treatment planning protocols, empowering your hygienists with the knowledge and support they need to thrive. Understand the pitfalls of over-relying on pre-authorizations and discover why it's crucial to take control of treatment decisions away from insurance companies.

In our next segment, we tackle the art of patient education for effective periodontal conversion. Learn how to seamlessly integrate patients' health histories into discussions about periodontal risks, helping them to see the value in their treatments. We'll also share strategies to ensure consistent communication from your hygienists to your front office staff, emphasizing the importance of proper billing practices. Stick around for our engaging wrap-up with Tessina, as we tie together key insights and prepare you for the exciting conclusion of our series. This episode is packed with actionable insights to help you elevate your hygiene department to new heights!

Want to learn Dental Coding and Billing? Join here:

https://tr.ee/efzYrY7mp-

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

Email Ericka:
ericka@dentalbillingdoneright.com

Email Jen:
jen@dentalbillingdoneright.com

Perio performance formula:

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


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


Speaker 1:

Thank you for joining us in this episode. We're so excited to talk about treatment planning. In the last episode we talked about how to diagnose right, like we talked about formula. We gave you the formula. You have the reports you need to pull in order to get that formula and a lot of offices probably realize they're not as hot as they thought they were right. So where do we go from here? I think today's episode we're going to talk about the treatment plan for increasing your perio performance, or hygiene performance as Jen puts it. So we just mentioned Jen. You just like gave me an epiphany about this whole episode being what did you call it Recalibrating your hygiene department.

Speaker 1:

Recalibrating your hygiene department. I love that because it's more than just the hygienist. This is all about empowering the hygienist, supporting the hygienist. We don't want our hygienist to already feel burnt out out, to feel like we're saying add more to your plate. We're actually saying let's support the hygienist in our efforts to improve hygiene performance. Right, where do you go from here? Now the offices realize that their perio performance is not as great as they thought. It was right, because numbers don't lie, friends. So where do they go from here?

Speaker 2:

I think there's a couple of different routes you can go. The first one is you know we talk about recalibrating your hygiene department, so what does that even mean? The first thing is we need to make sure that the team is working as a whole. So if you have three, four, even two hygienists, like where is that gap between the treatment planning between the two? Because there can be a huge difference. I mean, we've we've seen it right, erica and Tesna like we've seen offices where you only have two hygienists but they are on polar opposite sides of the treatment planning schedule.

Speaker 2:

Here we need to recalibrate each other, and a few things come into that. We need to make sure that periocharting is consistent not only frequency of periocharting, but actual numbers. Are we calibrated on our numbers? Because then we know what our protocol is as far as treatment planning goes for the patients.

Speaker 2:

Another key point to recalibrating is making sure that you have a protocol in place that makes sure that all of the hygienists are on board with the plan and we all know there's no question whatsoever what we're treatment planning. And then we can just move forward from there. And the last thing is going to be insurance benefits and eligibility, and that's something that Tess and I can speak to too, but we need to make sure that we know what the benefits are going to be. If we are, if we do have a periodontal protocol in place, what is the patient going to owe if they come in and we say, hey, we need to convert you to now this periodontal cleaning, more advanced cleaning, this is what you're going to owe, and so all of that comes into play when you're talking about a department. Even a hygiene department includes everyone, not just hygiene.

Speaker 1:

So I want to bring everybody back into our conversation that we were having yesterday. Because, tess, you made a really good point about pre-authorizations. Because we're coaches, right, so we work with offices to help them improve systems. And sometimes when we get together, we put our heads together and we're like how can we do better, how can we teach better strategies? And yesterday we were talking the three of us were talking about 4346 being downgraded to a prophy, right, and that is a question that has to be asked or doesn't have to be asked. But because we can create a strategy that works for the office without having to put more workload on the office, right, because 43, 46 gingivitis cleaning, gingival inflammation cleaning, as it's referred to is sometimes downgraded to a prophy, but we still need to charge for what we're doing, right, like if the patient is a gingivitis patient, we need to charge for what we're doing.

Speaker 1:

And I said I made the mistake and I told Ben this yesterday was funny. I said I triggered Tessina today. I used the term preauthorization and Tess was triggered. So I wanted to bring you into that conversation, like, let the audience hear your response to that, because it was epic. I thought it was great. So, tess, why do you not believe in submitting preauthorizations for things when we can't ask? We don't have the time to call the insurance company and ask is this procedure downgraded, right? And I said, well, maybe we just submit a pre-op. And Tess, and I was like, excuse me, no, I don't think so I loved that.

Speaker 2:

I love that so much.

Speaker 3:

I can get worked up about these things, right, I know you can. I am not a fan of pre-ops I'm sure you guys have heard me say it before. But a pre-authorization to an insurance company is we are saying like, hey, we don't know if this service is going to be covered or not. We're asking your permission if you think that you will consider it to be covered or not. We're giving them an avenue where they can say, actually no, it's not covered. Right, instead of us saying this is a service we did that was required for the patient, you are saying this is a covered service, therefore you have to pay for it. Right, we're not asking their permission and we're not thinking, when we're sending a pre-op, that that's what we're doing. We're thinking, oh, let's just check if it downgrades or not, but a hundred percent, that's what you're doing. You're saying to them we don't know. And you're opening this whole can of worms where they can bully you now and start dictating treatments, and we just don't believe in that, right, erica?

Speaker 1:

No, absolutely not, Absolutely not. I love how you refer to this as asking for permission, because I've never been a fan of pre-auth. In fact, in dentistry and I've said this for years we don't get pre-authorizations. In dentistry, we ask for them, but we receive pre-certifications, pre-treatment estimates, pre-determinations. They're not the legal term which, because pre-authorization is a legal term, it means we cannot pay less than what we have authorized and we don't receive those in dentistry, and I think that's a very common misconception. That is transferred by the patient into dentistry from their medical insurance. Right, it's not something that we should be even be bothering with, because it's more of an administrative approval. They're just looking at the plan benefits and going, yep, if, if we decide to pay for this, this is how much we'll cover. Right, like we have no recourse when they give us a pre-certification and say, but you said you were going to pay and they're like no, that was just an estimate.

Speaker 1:

You know, so I mean I agree with you a hundred percent. It was. I'm sorry, tess, it was a fluke mistake on my part. I was just trying to figure out, like in our conversation yesterday, I was trying to figure out how can we help our offices that are implementing, you know, through Jen's coaching.

Speaker 1:

She's saying hey, you have three different types of cleanings that you are in fact doing and your perio performance is low because you're not incorporating one of the biggest cleanings. You're probably doing more of the gingivitis cleanings than you are of the healthy prophy cleanings, right. And so we're going to help you recognize how to identify, how to document, how to bill all of that stuff. When she incorporates this new cleaning because a lot of these hygienists don't even know this cleaning exists or they don't know how to document it creates confusion for the front office because now they're like wait, the insurance is downgrading it to a prophy, so then just document for a prophy, right. Or even worse, when the insurance companies pay less than a prophy for the gingivitis cleaning and that's a conversation we can talk about later. Like and submitting, what do you suggest when we submit for a 43-46, the gingivitis cleaning and insurance downgrades it or insurance denies it. You know what's the recourse for that.

Speaker 3:

Yeah, so I think we have a couple of things here. So one I think that the front office, anytime there's something new, they feel like it's new and different. This isn't that new or different from the bone grafts and the membranes that were used to them, saying they're covered, and then they don't cover them or they downgrade them or whatever. And we already have our protocols in place for that right. We explain to the patient that this is what's being told to us by your insurance company. We're going to submit it for you, we're going to fight on your behalf, but ultimately you're responsible for the payment, right? So you collect from them. I always collect from them upfront, as if it's not going to be covered, and then, if the insurance pays, it's a bonus to the patient, right, we'll refund them. So I think that's the same strategy in place we would use for any of these other things.

Speaker 3:

4346 doesn't have to be. I'm going to collect a whole 4346 up front. Instead, you can use that like they say it's covered at 100%. But just so you're aware, sometimes they downgrade this, but it depends on so many variables that I can't know that right up front. I'm going to not charge you anything for today. We're going to bill to the insurance and then, once I get that back from them, I'll let you know. If you owe anything leftover. Yeah, and you can give them a range. Yeah, you can give them a range, even of, like it'll be anywhere from 30 to $75. And then they're like hey, I'm going to mentally prepare for 30 to $75 in 30 days from now or two weeks, and if you're on point with your stuff, you can say, like I'll let you know in about two weeks, right, when I get that payment from the insurance company.

Speaker 3:

But when the insurance company is sending you these downgrades and or paying a lesser amount, why aren't we pushing back? Why aren't we arguing that instead of just accepting it and saying, like well, the insurance said I don't know, they're the boss right. So we should be reaching out to first in an appeals process to say, no, this should not be downgraded, this should not be at a lesser fee, and appeal those items with the insurance company. You probably won't find a lot of success if it's written in your contract with them, but you can reach out to your insurance commissioner. Even if the insurance commissioner can't provide you an immediate relief to the situation, they can be made aware of this problem and you can ask your other colleagues to start sending in this problem, this complaint enough, to the point where, when they hear it enough times, they're like we've got to do something. This isn't right for the insurance companies to be doing this what was the state test?

Speaker 1:

I think you said was it Washington? Okay, talk to us a little bit more about that. I know you mentioned it in one of the previous episodes that you and I did together about the appeal process, but talk to us a little bit about how the power of notifying we're not always going to win when you get the insurance commissioner involved. However, as an industry, right as billers, we can have a bigger win, like for the greater good of billing. So talk to us a little bit about what just happened in Washington and how we're all benefiting from that.

Speaker 3:

Yes and I might not have the exact details. So I'm like I don't want to say the wrong thing, but if you're in Washington watching, thank you for your guys' hard work. But Washington all of the dental offices were complaining to the insurance commissioner about this bundling problem of the x-rays and the insurance commissioner went to battle and they actually got Delta Dental as a whole. So everywhere across the country now has been benefiting from what Washington pushed back on and they're still bundling some x-rays, but not like they were before. And that's where I'm like ah, those exact details I might be missing right now, but you guys can look it up. Go look up what Washington Insurance Commissioner did with Delta Dental and you should be seeing that. If you haven't already, I have. I've seen it come back on the claims. I'm like, oh, this is nice, Now my bite wings and PAs aren't being bundled, right, but they do still have that If you pay, if you have enough bite wings and PAs, that equals more than what they would have paid for an FMX.

Speaker 3:

They're still just going to pay that amount. So this is a new fight we have to fight, Right, but they did resolve some of the issue for us that if you just did one bite wing and one PA. They can't bundle that now or something. So it was so fun to see and I was like, so proud of Washington. I was like yeah, washington.

Speaker 1:

I mean and that's the point right Getting the insurance commissioner involved and reporting these patterns of abuse. Because the insurance commissioner is not there necessarily. I could be speaking out of line here, but I understand that the insurance commissioner is there to advocate for our patients' benefits, not necessarily advocate for our offices to get paid, but as a result of the advocacy you know for the patients' benefits or advocating for the patients' benefits, our offices get paid.

Speaker 3:

Yes correct.

Speaker 1:

That's the benefit right. The end result is advocate for your patient's benefits, friends, like it's really important that we take a look, we look at billing as an advocacy. Not, yes, of course we want our claims to get paid. We all have this level of I don't know. I find billers to be very, very proud of. You know their claims getting paid, like we all. We all kind of have this little streak in us that we're proud to say that our claims get paid and you know we get our claims paid down to the penny.

Speaker 1:

I remember back in the day, cause I've been doing billing since 1998. And I remember, before all these umbrellas and before all of this crazy borrowing of networks, it was just between you and the insurance company and you could literally anticipate down to the penny what your claim was going to get paid. There were some downgrades but I mean it was basic stuff like composites and crowns and that was it, but you could still calculate down to the penny. So we would like get super happy when our claims would get paid down to the penny. And now we're lucky when that happens. I mean it does still happen, but you really got to, we really got to know your stuff.

Speaker 1:

But I think, as with Jen's approach so where I was going yesterday when we were having this conversation about, you know, incorporating 43-46, jen's approach to perio conversion is not to shove it down the patient's throat. You know they're here for a prophy and then you know, oh, you have gingivitis and now we need to do a different cleaning and, yeah, you might have a copayment when you go up front. That's not what she teaches and you teach Jen to educate the patient where they are currently and next time when they come back, if this is still happening, which we all know, it's still going to be there because it's been there for the past five years. Talk to us a little bit about your method. And that's why, tess, I had mentioned the pre-op, but now I just mentioned it because it was a thought that came into my head and you immediately smacked that down Like so fast, so fast. So talk to us a little bit about your approach to that, so talk to us a little bit about your approach to that.

Speaker 2:

Yeah, so I call it prepping the patient. So in clinical hygiene, I'd say that we have to put the responsibility back on the patient. A lot of hygienists are very empathetic. We're very loving. We see these patients as our friends, which they are Honestly they are, but we also need to take care of them and they rely on us for that. So in a sense, we need to put the responsibility back on them.

Speaker 2:

Us diagnosing something is not us, like making them have gingivitis, and I think that's. There's a huge misconception there. And a lot of hygienists don't want to diagnose perio or gingivitis because they feel bad and they don't want to make them pay. Or they don't want to diagnose perio or gingivitis because they feel bad and they don't want to make them pay. Or they don't want to make the commitment because they know they travel a lot for work and their grandma's sick and all of these things that come into it. But really, when it comes down to it, they trust us to take care of them and if we do not diagnose gingivitis and SRPs and these things that take care of the patient, this is not a financial burden that we're putting on them and I think we need to take that completely out of our vocabulary, Like it's not our job to.

Speaker 2:

I always say this it's not our job to brush their teeth at night and floss their teeth. It's not our job to do their budgeting for them. That's on them. If we create the value for the patient and we prep the patient, as I call it, they will want the treatment because they see it as. But when we go in there and say you have gingivitis, you need this gingivitis cleaning and it's going to be $30. What do you think they're going to say?

Speaker 1:

Yeah, I'm going to immediately pull back. You know what are you talking about. I thought I came here. Why didn't anybody mention this to me? So let's go back to to the treatment plan, right? So in these offices their perio performance is not as hot. It's not at 60%, the bare minimum that you you talk about. And now they're like okay, I realize we need to incorporate the gingivitis cleaning. Maybe for some reason we're not doing as many SRPs as we thought we were. Walk us through that perio conversion conversation, right? Like walk us through the patients in the chair for a prophy and now they need they have gingivitis or they've had it. But now the hygienist has learned that we need to educate our patients and they want to walk us through that conversation.

Speaker 2:

Yeah, I'm going to back up just a little bit, because if we're all of the coaching, is one as a whole right. So we ask the hygienist ahead of time you know what? What do you think you struggle with? What do you think you do you have time for these things? And then we ask the front office what is your systems in place for insurance verification? So that kind of comes into the coaching too. We're using the same verbiage throughout the office. We know what the patient, what the patient, is going to have out of pocket if they are converted, and we kind of know if they're going to be converted initially, right. So all of that stuff comes into play beforehand.

Speaker 2:

Now, when I bring the patient back, I immediately go over their health history and anything that could indicate that they would have a higher risk of perio. I talk about that. So if they have diabetes, I'm like man do you have any problems with your gums? Diabetes can definitely lead to more periodontal issues and I bring that back into perio. And then, if they have, you know, if there's Alzheimer's, I make sure that the caregiver is aware of things that they can look for. If they have heart disease, you know you're more at risk for a heart attack if you don't get your teeth cleaned more regularly. These kinds of things I bring into the conversation.

Speaker 2:

Then, as we're doing x-rays, you know I see what kind of x-rays they need. I think we talked about this. The last one too, which is fine, but I don't always take four bite wings. Sometimes I take four bite wings in a PA if someone's some area that we're checking and I bill for that. Sometimes I take seven vertical bite wings and I bill for that, and Tessna can speak to this too, but sometimes they will downgrade to four bite wings. But if we don't start billing seven, how are they ever going to know that we do them? So we need to start billing that. If that's what the patient needs and you can see that alveolar crestal bone height and that's what I'm looking for with these perio patients and I'll talk about that you know I'll be like, oh, here's some vertical bone loss, let's check that area.

Speaker 2:

When we do our peri charting, everything leads back to perio. So now we go into perio charting and we do the perio chart and I always have an assistant with me because that way the patient can hear it. And when I'm leading them back I say you know, healthy gum tissues one to three millimeters, or indicates inflammation and gingivitis, gingivitis comment. And then four, five and above is periodontal disease and we'll talk about that if that's the case at the end. So in their mind they're, they're thinking about those numbers as they're hearing them. If they hear a lot of fours, or if they're sensitive while I'm period charting I go, oh, is that sensitive? And then, guess what, let's put desensitizer on or let's talk about why that could be sensitive.

Speaker 2:

Yes, it's a bill of code, yes, and while I'm doing the perio charting, if something is like sensitive in the gum tissue and it starts bleeding, I'll be like, oh man, that's, that's really an area that has a lot of inflammation and bleeding and then I'll move on. And so I just make little comments throughout the entire time. That puts the value in the cleaning at the end of what I'm going to treatment plan. And if when a patient comes in, you see their medical history and their x-rays, you know what kind of clean they're going to be. So that whole conversation leading up to after the perio chart needs to be about what you're going to treatment plan and why and clinically, why. We're not talking about finances here. But so after we peri-chart, I sit the patient up and I say, hey, you know, that area that was really bothering you when we were peri-charting, that's the same area I saw in the x-rays. I think we need to do a more advanced cleaning for you there. And by that point they're like, yeah, definitely that area hurt or whatever it is, and so it puts it back on them and I say, you know, I really would like to do, you know, one to three cleaning back there.

Speaker 2:

You know we can do your regular prophy today and I still I always do the least invasive thing first. That is for insurance purposes as well as taking care of the patient. I think if you start and you give them what they want with the prophy which is what they need to for the rest of the teeth right it's, the rest of the mouth is healthy. You can still do localized SRP on a couple areas, but that needs to be the next appointment and that first appointment. When you're doing, you know the prophy and you're talking about everything. Oral health instructions need to be in there. You're talking about what you can do to improve it for next time so it doesn't travel to the rest of the teeth, and there's all these conversations that happen. I mean I could talk for hours about appointments.

Speaker 1:

And, interestingly enough, we've learned that Delta Dental has an enhanced billing, enhanced program that will cover if the patient qualifies through a risk carries assessment tool we use. Oh my gosh, what is the name of the tool? Tool we use oh, my gosh.

Speaker 2:

What is the name? Of the tool, just like Carrie's risk assessment.

Speaker 1:

Yeah Well, it has to be approved by the American Dental Provisor. It has to. It's the one that's recommended by the American Dental Association and it has to be one of those tools, otherwise they they will not allow the enhanced benefits, because Delta has this agreement with Provisor, the enhanced benefits, because Delta has this agreement with Previsor. And so anyways, interestingly enough, if they qualify for the enhanced benefits.

Speaker 2:

They will cover oral hygiene instructions. They will cover tobacco counseling.

Speaker 1:

They will cover more perio maintenance. Delta will offer these services automatically. You don't even need to call and get a breakdown, you just have to use Previsor and Previsor is auto automatically connected with Delta. So they'll just offer these benefits. So it's not available in all States. I think it's available in like eight States right now. But I mean these are things that we should know to tap into, as you know, as advocates, right? Patient advocates, because we want to make sure that we're maximizing on all the things but also getting our providers, you know, reimbursed for what we are doing. You know, reimbursed for what we are doing, right? So it's, it's like a dual advocacy. We're advocating for our doctors to get paid, our hygienists to get the, the production, get credit for what they're doing and also get the patients the benefits that they need.

Speaker 2:

And the pre-visor is great for patients that have like are pregnant, and pregnancy gingivitis is a huge thing. You want to see them more frequently during that or during ortho too. Previso is a super helpful tool so they can get those gingivitis cleanings covered at a more frequent rate.

Speaker 1:

Yeah, and we'll put a link to Previso in the show notes For those of you that are wondering what that is. It is a free tool. There is no cost to use Previsor, and I'll put a link to the show notes. It's just a matter of integrating it into your day-to-day with your patients. But it gives a carries risk assessment, which is a billable code that you do not need enhanced benefits for. It gives a perio risk assessment and it also gives an oral cancer risk assessment. So you get those three risk assessments in one report and there's so many things wonderful codes that you can add to your billing repertoire, your toolbox, when you use these types of tools. I think that that's I mean we did. We covered a lot today giving them a treatment plan, talking to them about you know what they can do next. It's all about increasing perio conversions. I think that's what it boils down to, right? Jen?

Speaker 2:

Yeah, and I I think too, when we're talking about front office, to make time for SRPs, make time for gingivitis cleanings, like, block out that time and give your hygienist enough time, especially with new patients, to to really go in depth with their perio review and their assessments, because we're nothing without our assessments, like we have nothing to back it up clinically unless we have those things in place. So I think it it is a whole office conversion for a perio conversion, but it's definitely doable.

Speaker 1:

All right, Tess, do you have anything to add before we close out?

Speaker 3:

I don't think so the only thought I had had was, like, we mentioned, like that these people, our patients, are our friends and so we think we're protecting him by not mentioning it. Right, and like if it was your friend, really what would you say? And I think all of us in the dental field have our friends and family come to us and say, hey, my dentist said this is what I need. Like, what do you think? And you're like go get that done.

Speaker 3:

We're big advocates for our friends, Dennis. We're always like yes, if they said you need that, you better go get it done right now, Don't wait. And so we're always like yes, if they said you need that, you better go get it done right now, Don't wait.

Speaker 1:

And so we're doing a disservice if we're not really letting them know what's going on and giving them that opportunity to treat it and just not getting a bloody prophy right.

Speaker 3:

Yes, exactly, yeah, and making sure they have handouts too. It's a lot of information for them and especially if they've been coming for years and haven't heard about this until just now, it's like. It's like a lot to take in. So a handout at the end of the appointment I don't know what your thoughts are on that, jen. I think that's really helpful for them to read it over when they're at home and they can talk to their spouse about it. You know, and it really helps sink in for them what, what this change is that's happening in their oral health.

Speaker 2:

Yeah, and even if you're prepping them and they could potentially be that gingivitis cleaning next time, you're giving them some tools to be like hey you can still turn this around. Maybe they will, maybe they won't but you're giving them that chance and then when they come back they're like, okay, I really hope my numbers are better, and then again it puts that value in the tree.

Speaker 3:

Yeah, and they get so excited the ones that do work really hard at home and they do improve it. They are stoked. They're like I've been working hard and you give them an update that that area, that pocket is smaller. They are so happy and they really they're in charge again of their oral health and it's fun, it's a lot of fun.

Speaker 2:

Right.

Speaker 1:

Yeah, I love that, I love that, and on that note, we will close this episode out. Tessina, thank you so much for joining us, and Jen, I think the three of us will be back together one more time to finish up the series. So, friends, stay tuned as we wrap up the series in our next episode. Until then, bye, friends.

People on this episode

Head Shot

Ericka Aguilar

Host