The Dental Billing Podcast

Debunking Dental Billing and Hygiene Myths - Part 1

• Ericka Aguilar • Season 9 • Episode 1

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Unlock the secrets behind effective dental billing and become a champion for patient advocacy with our expert panel! You'll leave this episode equipped with actionable strategies to improve insurance reimbursement, combat claim denials, and ensure ethical billing practices. Join me, Erica Aguilar, alongside my colleagues Jennifer Lyman, Patricia, Tessina, and Amy as we dismantle common myths in dental billing and hygiene, revealing the crucial steps you can take to prevent claim denials and manage burnout among hygienists.

From mastering accurate coding practices to leveraging the power of the insurance commissioner, we cover it all. Tessina shares her expertise on creating strong claims by incorporating patient comorbidities, ensuring your submissions clearly demonstrate dental or medical necessity. Amy offers her proactive approach to fighting denials, guaranteeing that rightful claims are honored without unnecessary delays. This episode is packed with insights that will shift your mindset, enabling you to advocate more effectively for your patients and navigate the complexities of dental billing with confidence.

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:

It's nine o'clock, let's go ahead and get started, because we only have two hours with our audience and I know we've got a lot of people that have been anticipating this webinar. So let me kick it off by welcoming everyone to today's webinar. We're gonna debunk some dental billing myths, some hygiene myths, and we're just gonna talk about being a patient advocate. One of the things, one of my intentions for today's webinar, is to change our mindset around billing and letting go of some limiting beliefs, some old ways of billing. There are a lot of common misconceptions that I see floating around in these Facebook groups, a lot of really bad information, bad advice and there's some good as well, but I really want to debunk some of the stuff that I'm seeing floating around out there. I think the intention is good, but we have to understand that there are some things that we can do to advocate for our patients rather than bill right, and that's going to be things like incorporating the insurance commissioner, helping to change the behaviors of bullying behaviors from these insurance companies and how we're going to manage those things. So my name is Erica Aguilar. For those of you that have never heard of me, I am a dental billing coach. I help offices through my company, hidden Dental Profit. We are a full service billing company and we strive to coach our offices to better insurance reimbursement and stop the insurance bullying, and that's really what I want to talk about today. I want to help you identify some patterns that you may not be seeing in your billing department, and I am sharing the stage today with some pretty awesome individuals who are also passionate about billing and patient advocacy. We're going to talk about it from an insurance standpoint and then we're going to talk about it from a hygienist standpoint, and we have two amazing hygienists here today. We have Jennifer Lyman. Jennifer is our hygiene coach. She helps offices improve perio performance percentages, or hygiene performance as Jen likes to refer to it. She is amazing at helping offices go from I don't know Jen like a 10% perio performance to exceeding 60%, so that in of itself just boosts insurance reimbursement when we are understanding how to code for what we are actually doing and stop leaving that money on the table. We also have Patricia here, and Patricia is also a hygienist and she's very passionate about helping hygienists to code for what they.

Speaker 1:

You're going to hear a very common theme coding for what you're doing, increasing production in the hygiene department, helping hygienists to not get burnt out. We see a lot of that today. I know, jen, you and I talk to hygiene teams all the time Tessina, you as well, and I'm sure you see this in your practice, amy but we see burnt out hygienists all the time, and so we really do want to give you the strategies to avoid that, because our intention is not to add more to your plate. It is to give you ideas around how we can get paid for what you're actually doing, and not adding more to your plate, right? So, patricia, thank you so much for being here. We're really looking forward to your conversation around that.

Speaker 1:

And then Tessina, tessina for those of you that have not heard of Tessina, let me tell you she is a master of I don't know insurance denial management. I mean, you are the queen of like getting the insurance commissioner involved and really like helping the offices reduce denials and sometimes eliminate them, because, as we're going to talk about today, we're going to take, we're going to take a different point of view around denials. They're not what you think they are. And, tess, you have some amazing strategies that I can't wait for the attendees to hear about and learn so they can implement these strategies in their offices as well. So welcome Tessna.

Speaker 1:

And then we have Amy joining us. Amy, amy is an office manager and, from what I understand, she's like office manager extraordinaire. So I am really looking forward to hearing what you have to say about patient advocacy, amy, and the power of the insurance commissioner, because I know that that is a very big component. It's a regular feature in your billing cycle and I would love the audience to hear your point of view, because you're actually you're in the trenches, you're an active office manager and you are actively fighting back these denials, and I want to hear more about how you do that. So that is our speaker panel. So, without further ado, what we're going to do is we're going to actually ask each other some questions and then each of us have a myth that we are going to debunk. Jen, I'm going to go ahead and let you start this webinar.

Speaker 2:

So Eric and I work very closely together in the billing arena. We help coach each other through a lot of different things, and we talk about insurance strategies a lot. So what's one common strategy that insurance companies use that often leads to claim denials, and how can dental practices better navigate these situations?

Speaker 1:

I don't know if it's a strategy, more than it's not so commonly known, and I think that we need to understand that denials are.

Speaker 1:

It might be a strategy, but denials themselves are not because of clinical decisions. They are because insurance companies are trying to do what is referred to as cost containment, and through my research I've even learned that some insurance plans even give bonuses around cost containment. So if we can keep budgets within a certain amount, we can not pay so many legitimate claims because and that's the other thing we're going to talk about is clean claims and test, and I'm sure you're going to talk about that a lot too. But I think if dental offices understood that denials are not because anybody looked at that claim and said, no, the patient didn't need that, it is because of budget. If we realize that, we recognize that and we, if we don't agree with the decision because we feel like the patient did need SRPs, the benefits were available and yet we still received a denial. That's a very common conversation, right, like? We definitely want to make sure that we are looking at our denials from a budget standpoint, not from a clinical standpoint.

Speaker 2:

Yeah, they always try to nickel and dime everybody, including the patient, in that right. So how can the prompt pay laws be leveraged by offices to ensure those timely payments? And then, what role does documentation play in that process?

Speaker 1:

So I think, as a billing industry right as all of us as billers we need to understand our state laws and we need to understand how we can utilize these laws so that we can beat the insurance companies at their own game of denial management or denials right, because denials are a strategy in of itself and I know this because I've done the research.

Speaker 1:

Delta Dental has been fined $300,000, which is nothing to them, but it was as a result of improperly denying claims.

Speaker 1:

So, when we understand all of this and we understand our state law, one of the laws that I feel more billers need to know about is the prompt pay law, because the prompt pay law was created so that insurance companies don't put financial hardships on patients and on our providers and on our doctors, because it's like twofold right. So prompt pay law designed to make sure that the doctor gets paid in a timely fashion, so that the doctor doesn't experience financial hardships and cash flow issues right, because this can cause serious cash flow issues. And also, what happens when the insurance company doesn't pay for a claim? Right? They end up passing that financial burden onto the patient, right? So it's designed for two things One, get the doctor paid in a timely fashion so he or she can pay their bills. And two, they don't have to pass that debt onto the patient. So when we understand that that's what these laws are designed to do, we're better equipped to fight back when we see a denial that we don't agree with.

Speaker 2:

I know in Oregon there's an interest payment if it's over 30 days and the moment you say that to the insurance company or you put it in the remarks, they will pay it, like the next week. You just have to tell them that you know about it. So it's very interesting.

Speaker 1:

And that's the case with most states.

Speaker 1:

We all have interest that the insurance company is required to pay interest on those claims that have gone beyond the 45-day timeframe.

Speaker 1:

Each state is different in terms of the prompt pay log timeframe, but it's usually around 45 days, can go up to 60. But if they don't pay or deny before that prompt pay timeframe, they must pay. In some cases it's the policyholder, in other cases it's the provider, but they have to pay it, and a lot of times we allow these insurance companies to get away with not paying interest because we just don't even know that we're owed it. Right. So very, very important to understand. And so, right there, let me just say right here it was. Metlife in 2021 was fined $750,000 by the New York Department of Financial Services for failing to pay interest on overdue claims, and this was the only way that we are able to get the insurance companies to pay within these prompt pay timeframes is to report this behavior to your insurance commissioner. The insurance commissioner is there to advocate for our patient, and that's something that we're going to get a little further into later in this webinar.

Speaker 2:

Yeah, yeah. So why is it important for practices to be proactive in addressing those claim? Denials that we're all getting for claim denials Because they'd like to do that, and what claim denials that we're all getting for claim denials Because I'd like to do that, and what are some ways that we can reduce those within our practices?

Speaker 1:

So I think I'm going to start with part two, like part B, which is, you have to track your denials. You need to. In my opinion, what we do for our clients is we have a spreadsheet and we track denial patterns. We track additional information, request patterns. We're tracking all of that because the only way to reduce this or eliminate it is to start reporting these patterns and behaviors to the insurance commissioner so that the insurance commissioner can take a look at all of that and determine if this is in fact bad practices on the insurance company's part, so unethical bad practices in claim management. And if we're not bringing this information to the insurance commissioner, it may not be to get the claim paid, but ultimately it can be to change the way the insurance company is abusing that office, right. So I think once you start reporting the behavior, the insurance companies start to back off a little bit and I've heard some information on other podcasts, in some of these Facebook groups and Tessana, I'm sure you'll agree with me here but just doing an appeal is not enough. And the appeal process itself you guys and please listen to me and listen to me carefully the appeal process itself is a strategy to prolong paying a claim that they knew they needed to pay in the first place. It is part of that cost containment strategies that insurance companies use in order to delay making that payment, and that was found in some of these findings. Like Delta Dental was fined for improperly denying claims on their first attempt, so I think they called it the initial submission. So Delta Dental was fined for denying so many initial submissions that it raised red flags because these patients had benefits for these procedures that were being submitted. But Delta, and so was Cigna, and so was MetLife.

Speaker 1:

They were all fined for these practices and what these insurance companies bank on and this is in the findings, this is in the actual report what the insurance commissioners found were the governing entities that did these audits on the insurance companies. What they found is that insurance companies banked, bank on the fact that we, in most cases, most billers, don't even appeal because they don't have time. Right, we're one person, we're doing a whole revenue cycle. There's just so much time in a day. I am not saying that these are bad billers, it's just that they want to, they just don't have time. And but the challenge with that is that the insurance companies know this and they're creating strategies denial strategies, improperly denying claims in order to win at cost containment.

Speaker 1:

Okay, so I have the studies in our follow-up email. I will send you guys all of the references where you can read up about my research and the findings through these audits, because it's public knowledge and I think that we need to. I want to empower my fellow billers, I want to empower everyone to understand. This is not because somebody looked at a claim and said, no, I don't think, I don't agree with this patient needing SRPs. I'm just going to use that because everybody understands that Right. Sorry, jen, I know I have like these long answers.

Speaker 2:

It's all good things though. It's all good things and I mean we're talking about the insurance bottom line. You know the insurance company bottom line, but let's bring it back to, to, like, the practices bottom line. So what is the connection between you know our dental billing myths that we're all going to talk about and these practices bottom line, like? How can debunking these myths lead to better financial outcomes for these practices.

Speaker 1:

That's such a loaded question so I get a lot of inquiries. You know I've I've been doing this billing, consulting for 15 years and been a dental biller since 1998. And I think I was five in that year. So I I have been doing this a long time and one of the things that I see is the fact that we believe things because we try to build something once or twice and then it gets denied. And then and we do nothing about that denial, we just kind of go, okay, insurance doesn't pay for that, and then we start telling everyone else that that's not a covered vent, you can't build those things together.

Speaker 1:

So I think letting go of some of these very bad misconceptions about what you can and can't bill. As an example, I hear a lot of chatter around prophy and limited SRPs and I think I have this conversation on a daily basis with either a hygienist or a biller. Yesterday was both and I'm scheduled to have this conversation with, I think, three people today. So it's so commonly misunderstood that, yes, you can bill a pro fee with limited SRPs, but you've got to know what is needed in order to get that paid. And it's again advocating for the patient, so that the patient doesn't experience a financial hardship, right, like we want to get paid for what we're doing, either by the patient, because they should be happy to pay for the services that were rendered right. Good experience equals happy patient. Happy patients are happy to pay for what they receive. But if we just keep this strictly a billing conversation, there is no limitation to what you can and can't bill for. You should always be billing for what you do, okay, and coding for what you do. There is no exception to that rule. There is no such thing as changing apparel maintenance to a pro fee on a claim form to bill for benefit, right? So that's another common misconception.

Speaker 1:

You know that I want to debunk there. You bill for what you do and in the event that that insurance company alternates benefit, just anticipate the payment for a prophy on the off cleaning and charge the patient the difference to what you actually did. That's the right way to do it. If offices tell themselves, you know well, our patients would never do that. Or oh gosh, our patients are gonna get upset now that they have to pay, you know a copayment then I would dig a little deeper into your patient experience and try and understand why the patient would not be okay with paying their part for what they need, and that's a whole other topic. But I think you know, just debunking some of this information out there, that you can't bill for this with this. It's not going to trigger an audit. In fact, it might actually help you in an audit that you billed for what you did.

Speaker 1:

Because if what the clinical documentation says doesn't match what was put on the claim form, then there is such a thing as unintentionally committing fraud and guess what? False Claims Act, the Office of Insurance, insurance General. They do not care, intentional or not intentional, and ignorance is no excuse to the law. So it's very important that we understand bill for what you do, don't bill for benefit, and I would challenge some of these things that you're hearing around what you can and can't bill.

Speaker 1:

If you're doing a prophy Jen and Trish and the patient needs, there's an isolated area where you're gonna have to go a little deeper. There might be. There's an isolated area where you know you're going to have to go a little deeper. There might be. There's bone loss there. There's it. Yes, you can bill for that in addition to the prophy. We just have to understand how that gets paid. And, if I can just add really quick, jen, a lot of times when, when an office calls me and says, hey, you know, cigna is starting to deny our SRPs, or we tried doing the limited SRPs with the pro fee and it just keeps getting denied, I will ask them to send me the period chart that went along with the claim and almost 100% of the time it's an incomplete period chart.

Speaker 2:

And we will be talking about that even more. So that's my answer to that yes, and you totally took my myth.

Speaker 1:

You can't do limited SRPs in the same day, oh my God, I was like no, but you have to say about that as a hygienist. Come on.

Speaker 2:

Yeah, no, that's okay. No, I think all of those things are really great and speaking of that myth, we'll talk about this two more in the hygiene section but you have to bill for what you're doing. If you're going in and you're going subgingival and the patient has bone loss and you're doing a pro fee, you are committing fraud, as a hygienist, you have to do what you need to do for that patient and it's benefiting them.

Speaker 2:

They are paying for these insurance benefits. We need to make sure that we are doing the best thing that we can for these patients, that we are doing the best thing that we can for these patients, and that is all I am about. Erica knows this. Yes, I am a biller.

Speaker 2:

Yes, I own my own billing company but I'm also a hygienist first and so I really focus on patient care and if they need limited SRPs, they need to get limited SRPs to get towards health, regardless of billing. So that's my little spiel on that, sorry.

Speaker 1:

Passion feel on that. Sorry, passionate much, yeah, yeah, just a little bit, a little bit.

Speaker 2:

So, yeah, I think that's it for my questions for you, erica, if you want to take it over, yeah.

Speaker 1:

So I also want to share my myth really quick and I want to debunk it. My myth that I want to debunk today is that you need to send additional information when your claim is denied, and I'm going to stop there for a second. Now, when I get a denial, the first thing or I get a denial somebody calls me and says, hey, can you help me with this denial? I can't see why it was denied. The first thing that I do is I take a look at how the claim was initially submitted to the insurance company, because what I find is we make it too easy for insurance companies to deny our claims because we're not submitting clean claims, right, like we're not taking into consideration the quality of our attachments. We're not taking into consideration the quality of our narratives. You know, are they just too wordy and lengthy and it takes forever to make your point. And are we using diagnosis codes? You guys like diagnosis codes are here and they're not going anywhere. I know, jen, you're using them on a regular basis, you know it's just. Are we doing the things as?

Speaker 1:

As dentistry continues to evolve, one of the trends that I see is that when an insurance company is asking for additional information or they denied something. If I submitted a strong, clean claim and I know that and I go back to the breakdown of benefits and I see that those benefits were available to my patient, I am not going to submit more information and it's going to be a matter of you have everything you need to pay this claim. Pay the claim or we're going to report you to the insurance commissioner. I mean, it's as simple as that and Tessima is going to get into this. Tess, you're going to come up next. I know you're like bursting at the seams to like get to talk about this, so that's my myth. I am not going to. I'm not going to play the additional information game because I submit strong claims proving dental necessity always.

Speaker 1:

Sometimes we're incorporating medical necessity into that as well, because the patient could have comorbidities or risk factors such as diabetes, high blood pressure or the medication that they're taking, and we need to talk about that stuff. We need to let the insurance companies know. Here are the risk factors. I mean really strong, clean claims is my mantra. Clean claims with sufficient evidence proving dental necessity. And if I speak legal terms, I think the legal term, according to the insurance commissioners, is going to be health care claims without improprieties. So the insurance companies are manned. They have to pay our claims. If we submit a clean claim, no improprieties proves dental necessity or medical necessity, they need to pay that claim as long as those benefits are available to the patient right. So anyways, that's where I am and thank you, jen, for asking those questions.

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Ericka Aguilar

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