The Dental Billing Podcast

Episode 87: Stop Verifying Insurance Like It's 1995

• Ericka Aguilar • Season 11 • Episode 7

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Dental insurance verification is stuck in the 1990s, but insurance companies have dramatically changed how they operate—leaving dentists with surprise balances, frustrated patients, and a mess of accounts receivable. In this eye-opening episode, I reveal how insurance carriers are secretly leasing networks behind the scenes and potentially pulling your practice into networks you never directly signed with.

Drawing from a recent consultation where a practice saw their AR spike by $70,000 due to inadequate verification, I walk through exactly why checking just the basics—deductibles, maximums, and coverage percentages—is no longer enough. The game has fundamentally changed. Through leased networks and umbrella plans like Connection Dental and DentaMax, carriers can apply completely different fee schedules than you expect, even when you think you're out of network.

Most importantly, I share the specific questions you must ask during insurance verification to protect your practice: Are we in-network or out-of-network with this specific plan? Are we directly contracted or leased through another network? Which fee schedule applies to our office for this plan? Does this patient's plan fall under a specific PPO tier, group or level? These questions will transform how you set up patient accounts and present treatment plans.

Ready to stop the bleeding and take control of your insurance verification process? Download my free verification checklist in the show notes and start mapping your complete network participation status today. Your billing department—and your bank account—will thank you.

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Would you like to set-up a billing consultation with Ericka? She would love the opportunity to discuss your billing questions and see how Fortune Billing Solutions may help you.

Email Ericka:
ericka@dentalbillingdoneright.com

Schedule a call with Ericka:

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Speaker 1:

Okay, so here is the deal. I am in the middle of testing out new gear for my 2026 plan to take this podcast out of my house and into an actual studio, and today's episode was recorded with one of the many microphones that I am testing out and it definitely did not make the cut. I did not want to record this episode all over again because I really feel like the energy was just right, the message was good, but the audio quality wasn't so great. It's not horrible, but it's not my best work. I'm just asking that you bear with me through the audio weirdness and you may not even notice it, but I definitely did. It's all a part of the plan and I will be testing more microphones out as we continue to make our progress to the 2026 plan to take the podcast out of my house and into the YouTube universe. Thank you, friends, and let me know what you thought. Hey friends, welcome back to another episode of the Dental Billing Podcast. I'm your host, erica Aguilar, and in today's episode I'm going to start off and preface the episode with please have your insurance verifier first understand what they are verifying, because it is causing such a mess for those of us on the billing end of things, when we are posting payments, when the incorrect fee schedule is being attached to the plan or the patient's account inside the software, because they didn't understand or know what questions to ask. You can give anybody a script, right, like you can totally give somebody a script and say follow the script. Where the breakdown starts to happen is when they don't understand what they're asking and when certain nuances come into play and how to redirect the conversation to get the information that we need in order to not have so many holes in the revenue cycle. So lately I have been spending a lot of time having conversations about messy AR and I'm not going to get into that today, but I am going to talk about where I am seeing the holes and I'm hopefully going to teach you how to avoid these pitfalls and questions that need to be asked beyond insurance benefits.

Speaker 1:

Okay, we are asking insurance verification questions like we're still in 1995. Yes, we need to get deductibles, maximums, coverage percentages, we need all of that. And yes, we need all that put into the practice management software. That's like the oldest saga in dentistry since we have been introduced to practice management softwares, because when I started doing dental billing back in 1998, we didn't have well, my practices that I worked with didn't have practice management software. We operated off of pegboard and pencils and you name it. It was just so archaic. Now we have practice management softwares and so we need the insurance verification, all of the information we obtain, we need that put into the software.

Speaker 1:

But that's not where it ends. We need to improve on asking better questions that are going to help us set up that patient's plan more specifically, so that we can present more accurate treatment plans and we can have more accurate billing. Back in the day you could bill for a crown and you would get exactly what you anticipated to get from the insurance back, I mean down to the penny. And nowadays it just feels like we are seeing more and more surprise balances because insurance verification and the process and the questions that we need to be asking, friends, that game has completely changed and we're still asking questions that aren't helping us get ahead of the game. We don't need to play this game. We just need to know the rules so that we can have more successful outcomes when it comes to, you know, decreasing surprise balances when we are presenting treatment and then we bill. And so let's talk about network participation and the types of questions that we need to be asking so that not only are we getting accurate benefits, but we are also understanding how these plans are borrowing and leasing networks behind the scenes without telling us, and that means we need to change up how we're having conversations with our insurance verification reps, right? So we're talking about network participation status in today's episode, and this is something that is often not talked about. I know that insurance verification is already a tedious job and we're spending more and more time on the phones to get accurate information. And for those of you that are just pulling up a fax, friends, I understand we're all pressed for time, but if we don't make the time on the front end of the revenue cycle, the back end is just going to be a mess, and that's why I was talking about earlier.

Speaker 1:

I'm having more and more conversations around insurance verification and how it's affecting AR. I had one office recently call me and the doctor said my AR has gone up and about $70,000 and I can't figure out why. And the first question I asked him was may I see a copy of your insurance verification form? And sure enough, when I looked at the form, it was so basic that I understood how they were getting surprise balances. Now, keep in mind he is going through the negotiation process. So as you go through that process, you are going to be, you know, pulled out of networks, brought back in through other networks, and that's going to be a part of it. But because the office was not asking questions that I'm going to talk to you about today, they ended up with a spike in patient AR. So let's talk about how we can ask better questions and avoid that mess.

Speaker 1:

Before we get into those questions, I want to make sure that you understand. There are two ways that we can be contracted with insurance companies. One is through a direct contract, that is, directly through the doctor and the insurance company. That's, there's no middleman. Then the next one is what we're seeing a lot of lately, which is the umbrella plans or the leased network plans. It's when the doctor signs with a third party network like Dentamax or Connection Dental and they allow other carriers to rent access to your discounted fees. We're seeing a lot of this in the billing landscape today and this is why I wanted to create this episode.

Speaker 1:

All right, so let's talk about how leased networks are secretly affecting your practice Carriers. They're leasing networks to grow their provider base without building relationships. So what I mean is Cigna may want to provide access to more dentists in their network, but they don't actually want to incur the cost, the administrative cost, that comes along with building out all of those relationships with all of those providers. So what they do is they will go to, say, a third party and rent more space from or through a leased network like Connection Dental, like Connection Dental, and now Cigna can tell the employer that they have access to 80,000 providers across the United States and that makes it more enticing for the employer to want to do business with Cigna and provide Cigna as their dental provider, dental insurance provider for their employees. So that's great for Cigna. However, for the providers, the way that the dentist is informed about this is they will be given access to more networks of potential patients to their practice. The con to that is that when that happens, the insurance company let's just use Cigna can then choose to use a lower fee schedule associated with that leased network. So you may think, because you're calling Cigna, that Cigna's fee schedule is going to apply to that patient's account. However, they have borrowed a network from Carrington and now Carrington fee schedule is going to be the fee schedule that they're going to pay that patient's claim with. So, again, we have to ask questions that put us in a power position so that we know and we can anticipate how this plan is going to pay the claim for your office specifically. When we understand the rules of the game, we can then better anticipate what we should be asking and be getting ahead of.

Speaker 1:

When you are an out-of-net network office, you're not contracted Can this still affect you? Because I know that there's going to be a lot of you thinking, well, we're out of network with everyone, so that's not going to affect us, and that is not always the case. I just had an example an office call me out of network with Blue Cross, blue Shield called me and said they were very confused because they just had a patient call the office and say I found you on our website and, doctor, has been out of network with Blue Cross, blue Shield for a few years now. This office got pulled into an umbrella plan or a leased network, probably before they went out of network, and it's just been lingering and sitting there and now there's a patient popping up. But the real work that has to happen is we need to do some type of network participation status mapping in order to ensure that we are not in network through any other affiliation or third party with all of the other major carriers and umbrella plans. And this is where the real work comes in.

Speaker 1:

When we're talking about really understanding and building out a very strong billing department. It's going to start with understanding your network participation status and map that out. It is a tedious yet necessary evil for all billing departments, for all practices and for all of you group practices the rendering provider's NPI and their contracted status. It's important that we map all of our associates out. That's a conversation for a whole other day. So my point here is that being non-contracted doesn't always protect you if you're still tied unknowingly tied to a leased network. So get your practice mapped out with network participation status, because you'd be surprised what you find when you take the time to actually map it out and then you can gain control of getting out of network with any of those unwanted third-party affiliations. So really important there.

Speaker 1:

So let's get into the questions you need to be asking during insurance verification that are related to network participation status. Feel free to pause this and go get a piece of paper, a notebook and a pen and write these down. I want you to start asking these questions because this is going to change the game for you when we are entering the patient's information into the practice management software. And again, front end of the revenue cycle, friends, is always going to be heavier, so that we can lighten the load on the back end and have more accurate balances. Okay, so the first question is going to be are we in network or out of network with this specific plan? I know that sounds basic, but please don't assume anything.

Speaker 1:

Today, in today's dental billing landscape, it has gone haywire. And don't assume that you know, because affiliations are happening behind the scenes without your knowledge and this is not something that is available to you on the portal through the insurance company's website. This is not even on the patient's benefit document. So if you're asking for the patient to bring the benefit document from their HR department, this information is behind the scenes, between the insurance companies only. This is not a part of their benefit breakdown. So this is why I want you to include this on your breakdown of benefits, because the insurance company has this information. You just have to know to ask for it.

Speaker 1:

The next question is are we directly contracted or leased through another network? Very important because this is going to tell you who you are also affiliated with. So let's say that you are directly contracted with Cigna but you're also being recognized under, say, connection Dental. We want to understand that, because what's going to end up happening is your direct contract fee schedule is going to trump all other fee schedules associated with Cigna and it's important that we know that. But the next question that I'm going to give you is going to answer the fee schedule question anyways. Answer the fee schedule question anyways. So the next question is which fee schedule applies to our office for this plan? So, in other words, which fee schedule will you be using to pay for this claim, this patient's claims? Which fee schedule is going to apply? Because we may be calling Cigna, but this plan may be using Connection Dental's fee schedule, and if we don't ask that question, we will not be able to attach the right fee schedule, and you know how that goes.

Speaker 1:

The next question is does this patient's plan fall under a specific PPO network, tier, group or level? What do I mean by tier, group or level? I'm just going to use Delta Dental as an example. Delta Dental has three plans, three tiers, that you can participate in. You can participate in all of them or you can participate in one, or you may think you only participated in one, but you're participating in all of them. Delta has the infamous Delta Dental Premier, then they have the mid-level Delta PPO and then there's the lower paying DPO fee schedule. If you are affiliated with all three tiers but you're only using one fee schedule, we could be setting that account up for AR backup. Ar messiness.

Speaker 1:

You know, we need to make sure that we're trying to understand how we are contracted with each patient's plan in order to give them more accurate treatment plan estimates. Right, if we are in network with Premier, or we think we're only in network with Premier, yet most of your patients are coming in with PPO benefits and we are attaching Premier's fee schedule, we are going to be in trouble. We are going to have an accounting nightmare because we all know that Premier's fee schedule is much higher than the PPO and we may not know that we are in fact contracted. We did sign up for that tier. So, a we need to know how are we contracted with this plan? B we need to understand are there any affiliations associated with this plan that we need to know about and C see what plan levels, what tiers are we contracted with?

Speaker 1:

Like? Did I sign up for just Premier, like I thought? Or did the person who handled my credentialing get me in all of the plans? Because I think that's what happens a lot of times is dentists will open their own office? Is dentists will open their own office, hire an office manager or a biller who is not skilled in credentialing and contracting, because those are two different things Then they will be in network with every plan under the sun, not understanding how this is affecting their account receivables and their ability to collect and so many things that we can avoid by just asking the right questions. So now that we know what questions to ask, you might be thinking okay, well, just like the other office that I just got a phone call from about the Blue Cross Blue Shield patient, they wanted to know well, since we thought we were out of network with Blue Cross Blue Shield, can we just present our UCR fees to this patient and charge them the difference? And the answer to that is no is no. We have to honor the in-network fees for this patient's plan because you are in-network with this plan.

Speaker 1:

What we need to do is moving forward. We need to reach out to Blue Cross, blue Shield and find out who else we're affiliated with through that network or that plan and start the opt-out process so that we no longer show in-network with Blue Cross, blue Shield under whatever third-party umbrella we got pulled into. So again, going back to the mapping out of your network participation status, this is something that I recommend offices do at least once a year. This is so crucial because it helps us as billers to understand when balances don't just add up or our EOBs are not matching what we anticipated. There are a lot of holes there that we need to plug so that the revenue cycle is a little more buttoned up. You can't change the contract today so that patient should be seen as in-network, but, moving forward, you can change the future of your relationship with that plan by calling and starting to starting the opt-out procedure.

Speaker 1:

I think I made my point here, your friends. I think I just wanted to talk about how skipping these steps are gonna lead to messy AR and it's going to start with incorrect estimates and then surprise balances and then you're going to have high AR and clean AR starts with clean verification. And again, if you are using a third-party verification company, please make sure that they're going beyond just the percentages and they are also asking about affiliations, fee schedules. All of that because if they are not, they're not completing the insurance verification process. It's very important that we go beyond deductibles and maximums so that we don't create a mess on the back end.

Speaker 1:

All right, friends, I have created for you a printable download of the questions I recommend that you ask during the insurance verification process and a little bit more of a breakdown for each question so that you can get the information you need to be more accurate. Okay, friends? So, with that being said, if you have any questions about your verification process, please feel free to reach out to me. My contact information is in the show notes. You can always email me at erica, at dentalbillingdonerightcom, or reach out to me on Instagram, linkedin, any of the socials. I'm very active on all of them. I hope this added value to your day and see you in the next episode.

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Ericka Aguilar

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