The Dental Billing Podcast

Inside The Worst Dental Billing Case Of 2025 - Part 1 of 3

• Ericka Aguilar • Season 11

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We pull back the curtain on a “busy” practice that bled revenue because trust replaced systems. A full audit, legal counsel, and a frank lunch reveal how missing chart prep, no route slips, and zero checks led to fraud risk and wild collections swings.

• redefining chart preparation as the operational backbone
• why custom route slips create visibility and accountability
• how one-person control hides errors and tempts fraud
• what a full revenue cycle audit uncovers beyond claims
• Medicaid compliance risks when notes don’t match billing
• legal strategy when a key staffer becomes a liability
• shifting in-house focus to chart prep and eligibility
• capturing every dollar with family account audits
• pros handle billing; team owns preparation and handoffs
• building guardrails with audits, reports and daily reviews

Grab the chart prep and end-of-day framework in the show notes
Please leave a review, subscribe for parts two and three, and share this with your doctor or a fellow office manager


Grab the Chart Prep & End of Day Checklist and Guide here:

https://ericka-aguilar-dental-billing-expert.kit.com/products/chart-prep-checklis


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https://maxassist.com/book-a-demo-fortune-billing/


Join The Biller Acceleration Mentorship Wait List Here: (Only 5 Spots Left in 2025!!)

https://linktr.ee/dental_billing_coach

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

Email Jen:

jen@dentalbillingdoneright.com

Email Ed:

ed@dentalbillingdoneright.com

Schedule a call with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min


Perio performance formula:

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


Delta Dental Locum Tenens Form:

https://www1.deltadentalins.com/content/dam/ddins/en/pdf/dentists/locum-tenens-form.pdf





SPEAKER_00:

Well, hello friends. Welcome back to another episode of the Dental Billing Podcast. This is the final episode for 2025 and it's a doozy. It is literally the worst billing case I have seen in 2025 and probably beyond. So I'm gonna go, I'm gonna get into that. But before I do, I need you to lean in for this one because today's episode might be uncomfortable for some. It's not dramatic, uncomfortable. It's like real uncomfortable. This is going to be a three-part series where I'm gonna walk you through the worst billing cases we saw in 2025. You guys, these are not stories from Reddit. These are the things, these are these are not things that I heard through the grapevine or read in a Facebook group. These are real cases that came across my desk. And I want to say this up front because it matters. The worst billing case of 2025 did not start with fraud. It started with trust, blind trust, and absolutely no systems, specifically the system that I'm referring to is chart prep. Before I tell you the story, we need to reset the definition of chart preparation. I've heard this called appointment auditing, I've heard this called appointment scrubbing. Essentially, what it all boils down to is what we are doing to prepare for the patient's next visit in advance, so that we can do two things. We can give the patient a proper heads up with enough time so that they don't unnecessarily take time off of work just to come in and find out that their insurance is no longer active. I think that that needs to happen at least 48 hours in advance, right? So chart preparation to me is communication and so much more. So I want to redefine chart prep and what this has to do with the case study that I'm gonna go through with you today. Okay, so chart prep is not about sending clean claims. Chart prep is about operationalizing how we are preparing for the patient visit before the patient ever walks through the door. Okay. It's knowing why the patient is on the schedule, what clinical care is planned, what insurance has already paid, and what insurance is gonna pay for this visit, what hasn't been paid and why, what the copay is gonna be today, if there's an outstanding balance from a previous visit, if there's an aging claim tied to this patient that we need to address, maybe we need to get the patient on the phone with the insurance company because we're just hitting a wall that happens, right? And how all of this is communicated clearly through the visit. Chart prep works hand in hand with a customized route slip. I'm not a fan of using route slips from practice management softwares, unless you can customize it. I do believe in open dental you can, but I'm still much more of a fan of using a customized route slip that really checks off all of the areas that need to be prepared. Okay, so that route slip is going to create visibility, it's gonna create accountability, and most importantly, it's gonna remove the ability for one person to control everything. Okay, keep that in mind. So earlier this year, I had a doctor reach out to me for a billing audit. We have clients that sign up for a billing audit, an annual billing audit. They are happy with their in-house team and they just want a third party that is auditing and determining whether or not there's any funny business or if there's opportunity being left on the table in the billing department. So this client reached out to us for that. On the surface, the practice looked fine. He has a busy schedule, his days are completely full, and patients are coming in and out of the practice. But the insurance collections told a very different story. If I only looked at the practice based on insurance collections alone, you would think that they were barely surviving. The doctor himself, he could not reconcile it. He literally asked me, how can we be this busy and not see it in the bank? So we started where we always start when we're doing a billing audit. We start by auditing the entire revenue cycle, just not how we're managing insurance and claims. It goes far beyond that. We're talking about practice management usage. So are you using your software in a way, in a manner in which it is intended to be used? How about that? What is your insurance verification process? Are you asking the right questions? Are you getting the right information? So we take a look at that treatment plan coordination. We take a look at the quality of the x-rays, we're looking at clinical documentation. Does the clinical documentation give the reason for the treatment in terms of a diagnosis? We look at how payments are getting posted, and we're also looking at your follow-up systems. And that's just to name a few. We have a whole system when we're doing this. And almost immediately in this office, one thing became very clear. There were no systems in place. There's no chart prep, there was no route slip, and there's no checks and balances. So everything just kind of lived in one person's head. That would be the office manager. Now, the office manager, she's been with the office for 10 years, I think a little bit longer. And the doctor has blindly trusted her and also has referred to her as, you know, irreplaceable. And he would not know how to function without her, even though between you and I, the office is not functioning at all. And so when he started explaining how much he trusts her, we're seeing that there's no systems in place. It's it's just a mess. Everything's all over the place. They use a certain software that's very popular, and it was just completely being mismanaged, and it was just all over the place, you guys. I can't even begin to describe how messy. That's when our spidey senses went off, right? For us, it was like something's something's going on. Because when one person handles everything, no one else sees anything. The doctor had no real-time visibility because day sheets were being handed over a week later and they were incomplete. And what I started to notice is that the procedures that were on the day sheet were things that she wanted the doctor to see. But the reality was she was padding claims with procedures that were not done that day. He had no clear understanding of outstanding claims. He had no consistent financial handoff. They did not have a cash system. So this office is a heavy cash payment office. And there's no system to track what how much cash is being passed over the counter. And that's where things got a little stickier. And I'll get into that in a second. But essentially, he had no way to track whether what was being billed matched what was being done because he had no idea how to run reports, let alone interpret them. Because I do know a lot of doctors who know how to run the reports, but they're not interpreting them properly. And maybe we should do an episode on how to properly interpret your reports so that you're looking in the right areas. So this was not just a disorganized office. This office had no control over anything, and there was one person that controlled everything. So lack of control or when one person controls everything creates really bad things, really bad opportunity to happen. And if you are one as a practice owner that believes your office manager and office managers don't come at me because I'm not attacking anybody. So when you have an office manager that you trust, and it's okay to trust, I really want this to sink in. It's okay to trust your office manager. I want you to trust your office manager, but do the office manager a favor and have someone audit their work so that you are always in the know about what's going on. And that will further deepen your trust. And as one office manager from the past, I don't know if you guys know my story or not, but I ran multiple offices for a doctor who smack in the middle of my career with him, moved to Dubai. And I was left as acting owner to all offices. And it was the best experience of my career, but it was also the worst. But one thing I insisted on was having somebody check my work because I just didn't want to be accused of manage mismanaging or doing something that I was not doing, I really wanted to have a third party. And in my doctor's case, it was his brother who had an MBA and was very familiar with the dental business side of things. So he would come and check my work. And I absolutely love that. So if you want to do your office manager a favor, justice, whatever it is, have a third party come in and, you know, maybe annually, a quarter, quarterly check-in, have somebody else who is not emotionally tied to outcome give you a report as to how things are really going, how your revenue cycle is truly being managed. Because sometimes you're just going to find opportunity. And opportunity means that we find areas where we can increase collections, right? So again, this lack of control from the doctor created opportunity for this office manager. And as we dug deeper, we started noticing things were quickly turning into something much bigger. We found a lot of fraudulent billing, services that were billed but not documented, patterns that didn't align with like clinical notes. And I'm not going to get into the details of that, but med this is Medicaid billing. So you guys know Medicaid does not play. And we want to make sure for Medicaid offices that we are as compliant as possible. And this office was certainly just not taking compliance serious whatsoever. And finally, when we presented the findings to the doctor, I mean, if I could frame his face, he just looked completely, completely blindsided. And his first instinct in that conversation, he first got felt blindsided and then his face turned red. And then he just wanted to like terminate the office manager immediately, which rightfully so. I mean, you find out that your office manager is taking cash and your office manager is fraudulently billing because her incentive, her bonus is tied to collections. You know, it it was just so hit and miss with this office. One month insurance collections is 20,000 because she just didn't feel like doing any billing. And the next month, they've got 108,000 in insurance money because she decided to go ahead and bill everything that's been pending for the last three months. So it was just so all over the place. And so once he learned how bad it was and he understood why his checking account was fluctuating so much, he just wanted to terminate. He was angry. And this is where the story kind of takes a turn. He did not fire her. And it was not because he didn't believe us. He was scared. He was afraid of retaliation, afraid of what she might do, afraid of what she might report. And we ended up bringing in legal counsel. And I will never forget the words used to describe the situation. The attorney literally said, this office manager is a ticking time bomb. And that advice was crystal clear to us. He said, do not let her go right now. Do not upset her and do not tip her off. Because if she goes to Medicaid and reports this, she could receive leniency and a favorable outcome for cooperating. You guys, let that sink in. Okay, so now that we know the backstory, I'm going to tell you about how I took her to lunch. And I really just wanted to pick her brain. I wanted to talk to her about the compliance concerns that I had. The doctor and I had already spoken about how I was going to handle this conversation. And we took the attorney's advice to heart. You know, we definitely were not trying to tip her off, but we were trying to get compliance going in the office. I mean, compliance is everything, not just to billing, but overall, right? Like we just want to make sure that we are compliant. And so I decided I would take her out to lunch. And she had no idea how much I already knew. My team and I had done this analysis, and you know, we knew a lot. And in that lunch, friends, let me tell you, when she she figured it out really quick, how much I knew, how much I knew, how far her reach was into the noncompliance. And she rolled over on the doctor really quick. And I have no doubt if something goes down in this office that she's gonna roll over on him and get that leniency for cooperating. She blamed him for everything. She said to me things like, Told me to build this way, and I'm just doing what he says. And I've always wanted to be compliant. I have been asking the doctor for compliance for I don't know how many years. And she made him out to be this monster. And so I felt the need to just ask her, well, why are you still there? Especially in this climate, right? You guys, like it's so hard to find good people. She has the pick of the litter. I mean, she could literally go to another office and they would hire her because everyone's looking for someone with her level of experience because she does know what she's doing. Okay. I do have to say that. And one of the things that really stuck out in this conversation is that she openly admitted that period charts were never done during exams and that she filled them out herself. And that's part of the reason why she was so backed up with billing, is because she has to create her own perio charts. You guys. And she said this casually, like as if this was industry norm. Like, what, you don't create your own period charts? It was just so eerie to me that she was so comfortable having this conversation with me. And I told her, I am not a reporting agency. I'm here to get you guys compliant. I am here to report my findings. And doctor wanted me to sit down with you and go over the findings so that we come up with a game plan together to get compliant. And she said to me, verbatim, Erica, give me the checklist and I will follow it. Give me the compliance checklist and I will follow it. So this, you guys, wasn't just a rogue office manager. This was an entire system failure. It is an entire system failure. The processes or lack of the lack of chart preparation, the lack of accountability. It's crazy. And here's the part that I need you to hear as you're listening to this crazy episode. The practice wasn't a ticking time bomb because of one person. It was a ticking time bomb because there were no guardrails in place, no chart prep, no routing slip, no visibility, no shared accountability. And I always say this if you've ever been to one of my live workshops, you know I talk about how accountability is everything to get that needle to move, friends. And you can go to a workshop, you can learn a ton of new things, but and you can implement and it can immediately improve things. But if there's no accountability in place, it's slowly going to go back to the old process because we get comfortable. And when we don't have accountability in place to keep that progress moving in the right direction, then we find ourselves with um with no progress or lack of progress. Chart prep would not have erased the past, right? Because there's nothing that we can do to fix the past. It would have stopped the bleeding long before it got this far. It is one of the things that I find offices overlook the most. And there's a question that I get asked on a regular basis when I'm in a discovery call or talking to a potential new client who wants to know what is my staff gonna do if I hire a third party for billing? And I can tell you right now, if you hire a third party to take over billing, day-to-day claims, posting insurance payments, right, and following up on AR, there is so much left at the front part of the revenue cycle, meaning chart preparation. Your team can literally be prepared three days in advance for all of your appointments. There should be no stone unturned when it comes to understanding everything about that patient's appointment coming up. And that is usually where we shift the attention as we take over the billing process. We shift the attention for the front office to focus on chart preparation, focus on eligibility, focus on the breakdown being entered into the practice management system properly. Focus on calculating co-pays for the day. Focus on auditing the patient's account. Are there any other family members? Maybe we have one person of a five-party family. One of those members are coming in, and maybe the patient coming in today doesn't have any outstanding balances, but maybe another person in that family does. So it's an opportunity to really prepare, dig deep, understand, you know, what's going on with that account from a clinical standpoint. Do we need to take new x-rays? Are we looking, if the patient's coming in for a crown, is this a replacement crown? Is this an initial placement? Really understanding all the details that we need in order to have the smoothest process, smoothest visit for the patient. There's no question that that patient can throw at us where we would have to say, you know what, I need to call the insurance and find out. You should know these things. And so when an office asks us, what am I going to have my staff do when or if I decide to turn billing over to you guys, you're going to have them shift their focus to chart preparation, to scrubbing each account and the family members of that account, really being able to capture every dollar owed to the practice. Maybe there's a fluoride that was denied that we need to collect for this visit. Maybe x rays were denied. But because there's not proper chart preparation involved, we're letting that stuff slip through the cracks and it's not being addressed. And eventually what ends up happening is those balances get written off. They get adjusted off because the office usually will assume the responsibility of not paying attention to the balance. And then a year and a half later, we're like, why does this patient have a$65 balance? Oh, because the Profi was not covered, you know, three Profi visits ago and nobody caught that. So let the pros handle the billing. Let the pros handle the payment posting. Let the pros follow up on old AR. Let the pros do that and allow your team to now shift their focus to chart preparation because I promise that is the missing piece of the puzzle that most offices overlook. So if you want the same chart prep and end-of-day framework we use with our clients, you can grab it in the show notes. It's built for real implementation, you guys. It's not theory. And also, if this if this podcast brings you value, can you please do me a favor and leave a review? Subscribe if you don't want to miss parts two and three, because I've got some more doozies coming up. And share this episode with your doctor or another fellow office manager. These conversations are too important to keep quiet. This is part one of a three-part series. In part two, we're talking about end-of-day systems and how practices lose control after the patient leaves. In part three, we are going to talk about small, harmless shortcuts that quietly turn into catastrophic risk. And I'm gonna leave you with this. The worst billing cases don't start with bad intent. They start with too much trust and no preparation. If you want to see what proper chart prep actually looks like, grab the checklist in the show notes. I will see you in part two.

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Ericka Aguilar

Host