The Dental Billing Podcast

5 Billing Blind Spots Most Dental Billers Miss

• Ericka Aguilar • Season 10 • Episode 1

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Unlock the secrets of dental billing as we challenge the conventional wisdom surrounding Coordination of Benefits and reveal strategies that can revolutionize your practice's revenue flow. Ever wondered why patients with dual coverage often face billing confusion? We unravel these complexities and offer practical insights to enhance collections and maintain patient trust. This episode is essential listening for anyone looking to master the intricate insurance rules and avoid the common pitfalls that lead to billing errors.

Dive deep into the importance of a robust follow-up system to shield your practice against revenue leaks. Discover how strategic reminders and effective follow-up protocols can dramatically reduce your days in Accounts Receivable, boosting your financial health. We critique the flaws in current insurance verification processes and stress the necessity of proper data entry for transparent billing. Gain actionable steps for accurately presenting treatment plans to avoid unexpected patient balances and dissatisfaction.

Transform your billing practices with real-world solutions designed to enhance collections and patient satisfaction. Hear firsthand reports from billers on the front lines and learn how to implement necessary adjustments that align with clear financial conversations, especially with new patients. By adopting comprehensive appointment and financial policies, you'll foster greater transparency and trust, leading to improved patient retention. Don't miss this opportunity to refine your billing processes and tackle challenges head-on for lasting success.

Want to learn Dental Coding and Billing? Join here:

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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:

Did you know that the Coordination of Benefits Model Regulation from the National Association of Insurance Commissioners, also known as NAIC, is the backbone of how multiple insurance plans decide who pays what? The rules can get surprisingly complex, covering everything from who's primary when there's a spousal plan to how COBRA interacts with Medicare. In today's episode, we're going to be talking about five very common billing blind spots and we're also going to be diving into why so many billers find coordination of benefits confusing and the most common mistakes that can leave revenue on the table. We'll talk about how the coordination of benefits model hasn't seen major changes since 2013, but certain billing situations still trip people up, especially when it comes to determining primary and secondary payers. I'll share some of the latest guidance example of real world challenges and tips on how to confidently navigate coordination of benefit rules to maximize collections while staying compliant, among so many other things that we're going to discuss. Friends, now let's get started. Hi, welcome back to another episode of the Dental Billing Podcast. We're going to dive into all things dental billing and hopefully help you improve your practice's revenue cycle while avoiding costly pitfalls. Today, we are discussing some truly egregious billing blind spots those subtle yet significant errors that can undermine your collections, hurt patient trust and, in some cases, even lead to compliance risks.

Speaker 1:

In my work with Fortune Billing Solutions, where we support practices nationwide as a full-service billing company, I see these issues way too often. Many of us in dental billing learned on the job right. We picked up some good practices and maybe some bad habits along the way. Today I'm covering five of the most glaring and all too often common billing blind spots that could be costing your practice revenue and patience. So let's dive into that a little further. As I mentioned earlier, a lot of us started in dental billing through on-the-job training, which can be invaluable for learning the day-to-day processes. But here's the issue with that On-the-job training often comes with ingrained habits that aren't always best practice, and some of these practices can be downright egregious when it comes to billing accuracy and compliance and we're going to talk a little bit more about compliance further on in the episode. But you guys know that I am all about submitting clean claims and with that comes a clean, compliant claim right. So, as an example, we might assume that just because our claim got paid, it was billed correctly. And friends, this assumption and friends this assumption overlooks key billing principles and requirements and where these blind spots can cause real trouble. Let's deep dive a little bit more on the five critical areas that I see on a regular basis. I call these blind spots All right. I call these blind spots All right.

Speaker 1:

So the first major blind spot is over-reliance on predeterminations. A lot of billers mistakenly believe that receiving a predetermination is a guarantee of payment, but in reality it is only an estimate and nothing more. I want to talk to you a little bit about the difference between a pre-authorization and a pre-treatment estimate a predetermination or a pre-certification Because in dentistry we do not receive pre-authorizations. A pre-authorization is a guarantee from the insurance company that they are going to pay for these procedures. A pre-treatment estimate, pre-certification, pre-determination is not a guarantee. Think of it as an administrative approval only. It is telling you and the patient that if we meet the criteria requirements for payment, that then they will pay this amount. Now, that does not guarantee that amount, because at the time that the treatment is actually rendered we have to take things into consideration like the deductible plan maximums. You know we might not have the same amount available as we did when we submitted a request for a pre-authorization. So the point here is that, yes, we are requesting pre-authorizations. However, what we receive in dentistry are administrative approvals only, and those administrative approvals are pre-certifications, pre-determinations and pre-treatment estimates.

Speaker 1:

And I also want to point out that, according to Google, the number one reason why patients are leaving one-star reviews is related to billing conversations. In other words, patients are being told that they're going to get a pre-authorization. How many times have you heard someone call a patient and say we got your pre-authorization or your insurance approved the treatment, giving the patient the understanding that they received a pre-authorization? That is not the case. What they actually received was an administrative approval and it is not a guarantee of payment. So what ends up happening is we have these conversations with our patients implying that their treatment is guaranteed or is authorized by their insurance company. Patients are transferring their idea or their understanding of what a pre-authorization is from their medical side, because in medical, when they issue a pre-authorization, that's a guarantee of payment and they can't deny or downgrade treatment. They've approved it and they issued a pre-authorization number.

Speaker 1:

Pay attention to what you are receiving in your dental practice, because I promise you you are not receiving a pre-authorization. And I'm talking about PPOs, I'm not talking about Medicaid, I'm not talking about Medicare. For those of you that are accepting Medicaid, medicare and all of that, I am talking about traditional PPOs. We do not want to advise the patient that treatment is going to be 100% authorized and guarantee of payment with traditional PPOs, because there's no guarantee there. That is not something that the PPO will give. So having better conversations around the patient's request for a pre-authorization will help alleviate those uncomfortable times when maybe the insurance company gave you a pre-treatment estimate and still denied treatment and that denial.

Speaker 1:

I'm going to lightly touch on this, but denials, friends, are not always based on clinical merit. Sometimes denials are based on budget constraints. Insurance companies have things like cost containment, where they have departments that are looking for reasons to deny, and sometimes that is not because you did not submit a clean claim. A lot of times you did submit a clean claim and still received a denial. That is a clear indication of the insurance company trying to stay within budget, because if the insurance company paid every single legitimate claim that crossed their desk, the premiums for individuals who are purchasing the dental plan would go through the roof. So they have to cost contain what they pay. This is why I'm a huge advocate of incorporating the power of your state's insurance commissioner so that when the insurance companies play these denial games, we know how to fight back. And that is a whole other conversation that we can get into on a later date.

Speaker 1:

But I just want to talk about right here this blind spot of having a conversation with the patient implying that we are going to get an authorization or a guarantee of payment. I have this conversation so often that it just blows my mind how many people are not aware that in dentistry we do not get pre-authorizations, and a pre-authorization is a guarantee of payment. Pre-determinations, pre-treatment estimates, all of that good stuff. That's just an administrative approval, letting the patient know, or the office know, how much the insurance company will pay if they pay anything. So be aware of that. That's blind spot number one. Blind spot number two is going to be something that a lot of you may have heard about this, some of you may have not and that's going to be incorporating the use of diagnosis codes.

Speaker 1:

I encounter offices on a regular basis that have no idea that dental billing is trending right behind medical. In fact, I believe that dental billing at some point in the future and I'm not talking in the next two years, I'm talking like maybe over the next 10 years, dental billing is going to be absorbed by medical billing. That trend has already started. It's not a requirement, so I'm not saying that you need to do this today, but I do think it is one of those blind spots that can become a bigger challenge when insurance companies start requiring diagnosis codes are placed on a claim form. I mentioned earlier that we have a full service billing company and we've already started to see denials for some of the self-funded plans, requesting diagnosis codes on the claim form for things like extractions, fillings, crowns, buildups and SRPs.

Speaker 1:

So if these self-funded plans which, by the way, we bill more self-funded plans than we do commercial plans or fully insured plans, we need to pay attention to the trends, right To patterns, and one of the patterns that I'm noticing that's really scaring me, I'll be honest with you is that I have conversations with billers every single day, during the week several times a day, and these are billers that are very strong and they know their stuff, but they are unaware that insurance companies soon I don't know when exactly I know that the self-funded plans have already started requiring diagnosis codes. This is going to become a thing and I want you to be that early adopter and don't be a lagger in the sense that when this happens, there's not going to be a big announcement, you're just going to see an uptick in denials. And when you start to see that uptick, I want you to know that it's most likely, in the future, going to be because more and more insurance companies are going to start to require diagnosis codes. So I am a big fan of learning how to incorporate diagnosis codes onto a claim form. Stay tuned, friends. I am going to be doing an episode on a couple of things. So one is I'm currently working through a process on how to incorporate the insurance commissioner into your appeal process, and I'm also going to be working on an episode on how to incorporate ICD-10 codes your diagnosis codes onto a dental claim form. This also gives stronger evidence proving dental or medical necessity as you submit your claim. So stay tuned for that. I'm working on those episodes slowly, but I will get them out there. So double check your coding. If you have the coding book the CDT coding book they have put the dental related diagnosis codes in the back of the book and it makes it really easy to reference which diagnosis code you should be using. I will also say that if you plan on doing this, you're going to need to reach out to your practice management software, and some softwares need the diagnosis codes to be turned on. If you will like, they need to be added to the codes that are available to you, as you were codifying interactions between the patients and the providers.

Speaker 1:

So, lastly, about the diagnosis codes, we have to start incorporating the diagnosis code into the exam process. So when treatment is diagnosed, we would attach the diagnosis, the specific diagnosis. So, as an example, it would look something like doctor doing his or her exam and the assistant putting the treatment into the practice management software. We know that. You know we would highlight the tooth and then highlight the procedure. Like Open Dental has the quick buttons. You know you would highlight the procedure or the quick button associated with what that tooth needs. Well, what you would do is incorporate the diagnosis.

Speaker 1:

So let's say that tooth number nine needs a root canal due to an abscess. Highlight tooth number nine. You'd go to your diagnosis code. You would type in abscess and it would give you all the reasons. Or irreversible pulpitis you type in irreversible pulpitis and then it would give you the diagnosis code. So you would highlight that diagnosis code, then go over to your quick buttons and you would then attach the treatment needed for that tooth. That's the only difference. And, as a biller, when we go to bill that root canal, the diagnosis code will auto-populate onto the claim form. That doesn't mean that we need to switch to that model right away. Learn how to incorporate diagnosis codes not only on your claim form but also into your exams and the diagnosis, because it is going to provide more evidence and a stronger claim when we start to put those diagnosis codes on the claim form. I hope that this has helped you guys understand why I have been preaching for years. Just learn. Don't maybe don't do yet, but learn how to attach a diagnosis code, or learn how to discern which diagnosis code goes with which procedure, and it's going to be customized, right Like not. Every patient is going to be customized right Like not. Every patient is going to need a root canal due to irreversible pulpitis. There could be many other reasons why that patient needs a root canal, but learn how to reference your diagnosis code for your treatment.

Speaker 1:

Now we're going to move on to blind spot number three. We're going to move on to blind spot number three, and this one still surprises me, because I just can't believe that we have such inadequate follow-up on outstanding claims still. It's almost like some billers feel like follow-up is an afterthought or one of those things that you do when you have time. And this is such an important element to the billing cycle and it just boggles my mind how many people mistreat follow-up. There's just inadequate follow-up or there's no follow-up whatsoever. So this blind spot is just happening way too often and I see practices submit claims and then simply wait, assuming payment will come through in a timely fashion.

Speaker 1:

But without a structured follow-up, claims can and they will fall through the cracks and this is going to lead to serious revenue leakage. That's what I like to refer to it, as we recently helped an office recover about $10,000 in outstanding claims simply because they didn't have a follow-up system in place. Some claims had been sitting in queue in the AR for over 600 days. Months can go by without any follow-up and these claims were essentially just forgotten about and the oversight can have a devastation on cash flow to the practice and I mean it's obviously going to reflect poorly on the practice's billing cycle. When you have better follow-up protocols, like setting reminders to revisit any unpaid claims after 30 days. That seems simple, but for some reason it's not commonly done and it's just going to ensure that we don't have any revenue slips right and we don't want any of these claims falling through the cracks. It's such a small but crucial step and it's so simple.

Speaker 1:

One of the simplest ways to avoid revenue loss is having a strong follow-up process. When you have that outlined and documented, then you should see that your days in AR, or how long it's taking you to close a claim, should significantly drop. So if you are interested in learning what your days in AR currently looks like, then feel free to reach out to me. My email is in the show notes and I would be happy to walk you through how to measure your days in AR. A lot of you know if you look at your AR and it's a mess or it's 30 pages, a lot of you already know that your days in AR is going to be pretty high, but I still encourage you to know where you're starting.

Speaker 1:

It's always good to have that comprehensive baseline of where we are when we want to do better, right, in any situation, in anything that we do, you go get a personal trainer. They're not going to say we don't need to weigh you. They're going to weigh you and that's going to be their baseline. They're going to make your goals based on your baseline. The same thing is going to happen when you start to work with me or my company. We're going to baseline everything and we're going to see where we are and then we're going to set goals to improve days in AR. We're going to see where we are and then we're going to set goals to improve days in AR. We're going to improve perio performance percentage. We're going to reduce the amount of time that it takes to get your claims paid. There's so much that we can baseline so that we understand where we're at and where we need to go in order to meet that goal. Whatever your goal is, this is a biggie.

Speaker 1:

This one I see all the time and there's so many myths I don't know if you guys heard me clapping my hands when I said that, but I did so many myths around coordination of benefits which plan is primary and which plan is secondary. This also causes confusion with the patients. When a patient has dual coverage, it can be a little complex, right, I'm not gonna lie, it can get a little confusing. I've had patients have four PPO plans and you're just sitting there pulling your hair out trying to figure out where do I put each of the plans, because sometimes it's not as simple as we think it is right. But mishandling it is a surefire way to frustrate patients and miss out on secondary payments. I've seen cases where the primary claim was processed yet the secondary plan wasn't billed correctly and in one case a secondary claim was filed without proper coordination of benefit documentation and it left the patient to have to pay more out of pocket. This severely damaged the trust between the dentist and the patient and that patient ended up leaving a really horrible review.

Speaker 1:

So it's really important that we understand how to navigate through the coordination of benefits process. You really need to understand this so that what the coordination of benefits rules are in order to properly position primary and secondary. Because if you know there's duplication non-duplication of benefits which applies to the secondary plan only, but sometimes offices are not even asking if there's standard coordination of benefits with each plan and when you're calling the secondary plan specifically, you want to know if there's a non-duplication of benefit clause in that plan, because if there is, then the secondary plan is not going to pay for the same service if it's the same percentage or higher for the secondary plan. And that's just one of the rules we have to understand how to navigate through coordination of benefits and how to properly enter our dual plans into your practice management software so that your treatment plans are coming out accurately. And I see a lot of offices you know, I'm just going to go there I see a lot of insurance verification companies that aren't doing this right, and if your job is to verify insurance and put it into the system, then get it in there right.

Speaker 1:

It's just so frustrating as a billing company. My billers will come to me and tell me what they're seeing and they're just doing it themselves. It's really sad how often the insurance verifier either in-house or third-party insurance verification company, is verifying benefits and only uploading it to the patient's document center and waiting for the office to put that information into the software. That's all your third party company does for you. Then find a company that's going to put the information into your practice management software, because that's the only way to do it right.

Speaker 1:

There's no point in verifying benefits if it's not put into the software, because the point of putting this information into the software is so we can present accurate numbers to the patient, we can bill accurately and we don't have surprise balances which, as I said earlier in the episode, surprise balances are practice suicide. I mean, it is so unnecessary to have a surprise balance if you're doing proper insurance verification, asking the right questions, attaching the fee schedules to the patient's account. I can't tell you how many offices don't do this. You guys, it is one of those things that drives me absolutely bonkers. Why would you not want to use your practice management software the way it's intended to be used? I don't understand that. And there are so many of our clients that, despite our request to attach the proper fee schedule to that patient's account, it is not done, and I'm talking contracted providers still wanting to only have the UCR fee schedule attached to the patient's account. Our billers catch that and it's one of the things that comes up in our meetings or in our day-to-day conversations. It's requested that the office allows us to attach the correct fee schedule to that patient's account so that, moving forward, everything can plug along smoothly. So this one is definitely coordination of benefits smoothly.

Speaker 1:

So this one is definitely coordination of benefits. It's part of the insurance verification process asking does this plan have a coordination of benefits clause. Is it a standard clause? What type of clause is it? Sometimes the plan will have a non-duplication of benefit clause. So you want to ask those questions because without those questions being answered you will not be able to position properly the primary and the secondary. I am not going to get into the details about how do we determine primary and secondary in this episode.

Speaker 1:

I just wanted to bring it to your attention that this is one of the billing blind spots that I commonly see and we have to understand what the rules say in the coordination of benefits 50 page regulation outline. I've read this thing, I read it every year and I make sure that nothing has changed and nothing has changed and nothing has changed in quite a few years. But I still come back and revisit it annually so that I know that how to navigate through the coordination of benefits I don't want to call them laws. More than one plan is going to participate in payment, so insurance companies will follow the provisions, the outlines outlined. What am I trying to say here? The insurance companies will follow the guidelines. There you go. That was the word I was looking for the guidelines in this 50-page document, and it can get a little sticky. If you don't know what these guidelines entail, I strongly recommend that you look up the Coordination of Benefits regulations and read in detail what these guidelines say about positioning the insurance dual plans, primary and secondary, according to these guidelines. So I'm probably going to do an episode on how to navigate dual insurance and I want to make sure that I have all of the information out there so that you can understand how this works.

Speaker 1:

Now we are in the final blind spot that I see on a regular basis. This is just wow to me, because we have a lot of billers who are still not making adjustments or adjustments reviewing any necessary write-offs when they are posting payments. I see a lot of billers and billing companies, for that matter, right. So I have reviewed, you know, both inside billing department performance and I've reviewed outside third-party billing, and it's astonishing to me how a third-party billing company would say that auditing a patient's account when they are posting a payment is an additional charge, and that, to me, is ridiculous. I can't even imagine charging our clients to make sure that the balance or credit is accurate. I mean, that's the point of doing your job. And then some right, like I am always trying to encourage our team to go beyond what the client is paying for. I want to create an environment of and then some billers, and those are the only types of billers that I want. On my team I see a lot of opposite of and then some. It was funny because Jen and I were having a conversation a couple days ago about the culture of the company and we're doing a pretty good job of creating a culture of and then some billers. And we're not the biggest company but we are growing steadily and we're managing that growth by making sure that our billers follow that and then some type of protocols that we have in place, and part of that is going to be making adjustments and making sure that if a patient has a balance, is that an accurate balance? Right? If the patient is left with a credit, is that an accurate credit? Understanding how to say the patient has a balance, we send a statement, a link, a text, something to the patient so we get that balance cleared up as soon as possible.

Speaker 1:

So write-offs may seem harmless but when they are ignored they can result in substantial revenue losses and these errors that go unchecked can cause AR nightmares. We had a practice that discovered a billing software glitch that was incorrectly writing off fees without their knowledge and over time it went unchecked and the write-off amounts went into the thousands of dollars in lost revenue and patients received inflated bills due to the mismanagement. So when you're not reviewing write-offs and adjustments on a monthly basis, you have no idea what chaos could be brewing, what storm could be brewing. It's like a hurricane that just gets stronger and stronger. So you really want to make sure that you implement regular write-off reviews and sometimes you might have to scrutinize some of these adjustments and make sure that we are preventing small errors to escalating into costly problems and by costly friends I don't just mean claim denials.

Speaker 1:

A lot of times if you ask a patient because I've done this, I asked our patients. A lot of you know that I've been a partner in two dental practices and the most recent practice was in Carson, california. I asked our patients, our new patients, why they left their previous practice. What made you make a change? And not 100% of the time, but I would say 80% of them said because of billing issues. They charged too much. They told me my insurance was going to cover it and it didn't. They lied to me what that told me was we need to have more accurate and better conversations around how their plan benefits work so that if, in the event, dental insurance denies a treatment or downgrades a treatment, leaving the patient with more out of pocket than we anticipated, we have to be able to have that conversation without confrontation.

Speaker 1:

Because when you have that conversation before it happens and you have them sign a financial policy that says listen, this stuff can happen. Also, we're going to give your insurance company 60 days to pay the claim and if it's not paid by, then you will. This stuff can happen Also. We're gonna give your insurance company 60 days to pay the claim and if it's not paid by, then you will be responsible for it. But these financial conversations have to be intentional. It is not our responsibility to hold the patient's hand.

Speaker 1:

To the extent that we enable them right, they need to understand their benefits on their own. So we need to make sure that we enable them right, like they need to understand their benefits on their own, so we need to make sure that they understand. What we're doing for them is because we want to make sure that there's no surprises, not for the doctor and not for the patient, but having some of this in place, to have the right conversation at the right time, particularly when you have a new patient and you get ahead of potential repeat offenders on the schedule, people who make an appointment and don't show up and there's no consequence to that because we don't have an appointment policy in place. That's a conversation you want to have ahead of time with a new patient and just have them understand what your appointment policy looks like, what your financial policy says about having insurance. So if you are a patient that has PPO insurance, this is how long we're going to give your plan to pay. Have them initial next to that because I promise when the plan downgrades or when the plan denies, it will be easier to have that conversation because they'll remember that they initialed. Most of the time they do, they'll remember that they initialed next to that policy that says, oh, insurance was going to pay in 60 days, or they denied and I'm going to be responsible. They will remember that and it will be an easier conversation. They're more willing to pay for the services that were not covered. You may have to work with their budget because this is a surprise to them as well, but the point is having the right financial conversation when you need to have it. In my opinion, that's the new patient visit will lighten the load when you have to have that conversation and not lose the patient. They will not feel like they were baited and switched, because a lot of times that's how they feel. They feel like you lied to them because we used verbiage like we've received your pre-authorization, let's go ahead and get you in. Or we've received your pre-authorization and insurance has approved that implant when they actually haven't. This is not an approval, it's an estimate and we have to remember that.

Speaker 1:

So let's recap the five egregious billing blind spots that can undermine your practice's revenue and reputation. One was the over-reliance on predeterminations. Two is incorrect or lack of usage of the diagnosis codes. Three is inadequate follow-up on outstanding claims. Four is ineffective handling of coordination of benefits for dual insurance. And the last one is failing to review write-offs and adjustments. Each of these areas may seem minor in isolation, right, but together they can have a severe impact on your practice. So addressing these blind spots not only protects your bottom line but also builds stronger trust with patients and it's going to ensure compliance.

Speaker 1:

And friends, remember, these are not theoretical scenarios, these are scenarios that we see every day. My billers report to me. They're seeing and encountering these issues on a daily basis and I can tell you from experience that making these adjustments will lead to tangible improvements in collections and patient satisfaction. So that is it for today. I appreciate you tuning in for today's episode and if these insights resonate with you, friends, please subscribe, leave a review and share this episode with your team. As always, I'm here to help you close these gaps and optimize your billing practices. Reach out to me if you're ready to make sure none of these blind spots are costing your practice, revenue and patience. I'll see you in the next episode, friends.

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Ericka Aguilar

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