The Dental Billing Podcast

Worst Billing Case of 2025 - Part III - Harmful Habits that Feel Harmless with Jennifer Lyman RDH

• Ericka Aguilar • Season 11

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A weekend meetup in Phoenix turned into a deep dive on the “harmless” shortcuts that quietly drain dental practices and invite compliance trouble. We compare notes from a brutal 2025 billing case, unpack the defensiveness that often surfaces when a third party steps in, and show how audit trails reveal everything from embezzlement red flags to training gaps and inefficiencies you’ll never see on a P&L.

We get practical fast. You’ll hear why copay waivers and frequency misses aren’t favors, they’re liabilities; how a real chart prep process (CPP) prevents four- and five-figure monthly losses; and why templates should be fillable, not filled, to protect patient specificity and accuracy. We talk clinical notes as legal defense, route slips that actually bridge back-to-front, and the non-negotiable role of periodontal charting. If AI is reading your claims, missing perio data is a hard stop. We also tackle credentialing vs contracting, rendering provider rules, and the spreadsheet every office manager needs to track participation status and re-credentialing dates.

On the clinical side, we break down case acceptance without pressure: narrate findings, ask better questions, and move patients appropriately from prophy to SRP or 4346 when gingivitis is the true diagnosis. And yes, we address the controversy head-on—billing 4346 is about medical necessity and compliance, not what pays 100 percent. Bill what you do, document why you did it, and let systems carry the weight.

If you want fewer denials, stronger compliance, and calmer nights, this conversation gives you the scripts, checklists, and mindset to get there. Subscribe, share with a colleague who needs the nudge, and leave a review telling us your biggest compliance headache—we might tackle it next.

Schedule a demo with MaxAssist to unlock scheduleing potential here:

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


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

Grab the Hygiene Billing and Coding Playbook Here:

https://stan.store/hygieneunlocked

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:

Jen, welcome back to the podcast. It's been Yeah, it has.

SPEAKER_03:

Thanks for having me.

SPEAKER_00:

Yeah, it's so weird. We're like, I don't know, maybe a hundred feet away from each other in our own hotel rooms. I know.

SPEAKER_02:

I know. We're having a good time though.

SPEAKER_00:

Oh my god. I I think we should tell the listeners what we've been up to because it it's been so much fun, but also it served such a big purpose. So I think for those of you that don't know Jen, Jen is a hygienist now biller, and she is amazing. She owns Lyman Revenue, Lyman Revenue Solutions, and she has her own billing company. She also works with us at Fortune. And her clients absolutely love her. So Jen and I have been collaborating on so many things, and we're working on something that we can't talk about on the podcast. But I'm sure that a lot of you will hear about it very soon. And we thought it would be a really good idea. Actually, Jen thought it would be a really good idea for us to take a trip and finally meet in person because we have never actually met prior to this past weekend. So this is the first weekend in January 2026. And I think it was like mid-December. You were like, let's meet in Phoenix in January.

SPEAKER_03:

Yeah, because I live in the snow.

unknown:

I don't want to live there.

SPEAKER_00:

And it has been rainy, so it has been raining so much in California. I know, I know, typical California, and it's like, oh my god, a little rain, and you guys are crying.

SPEAKER_02:

Yeah.

SPEAKER_00:

But I can't help it. We're spoiled like that. So here we are in Phoenix, uh, Tempe, Arizona. And we are gonna go hang out at Dentaltown tomorrow. Take us out for some amazing tacos. I've been to this place before, you're gonna love it. So we have a full day. We have like we've been doing so much today. Jen and I were content creators and we were running around this hotel scouring out every place that would be a cool spot to record content and b-roll. And it was our first time, both of us doing it. And you guys, it's so exhausting to I was so tired. I was so tired. Could you tell towards the end I was over it?

SPEAKER_03:

Oh, I was too. I yeah, I could tell you were over it, and so was I. I was like, all right, let's get these last thoughts.

SPEAKER_00:

I I love it. Like, and I think what we were doing for those of you that that don't know what this is, so we were recording a lot of B-roll, and I don't know what the V stands for, do you?

SPEAKER_03:

I don't know.

SPEAKER_00:

I don't know either. So, but it's called B-roll. So we were going around the hotel recording a bunch of B-roll for 30 days of content so that we could record something every single day or post something every single day so that we could be more consistent. And excuse me, that was fun and exhausting. And Jen had the whole thing mapped out, like she had it so organized. Like, here's the B-roll for the hotel room, here's the B-roll for the lobby. We have a rooftop lounge. So we did B-roll on the rooftop lounge. I mean, you had it all. We were walking in and out of the elevator recording ourselves, and people were looking at us, what are you crazy ladies doing?

SPEAKER_03:

I didn't care at that point.

SPEAKER_00:

I know that was what one of those ladies said. You have to get used to doing cringe.

SPEAKER_03:

Yep, it was cringy, but it was worth it.

SPEAKER_00:

So oh my god, it was so good. So hopefully you guys are gonna see that here very soon. So today we're going to wrap up the last episode to the series, the worst dental billing case we saw in 2025. And I think that this is appropriate. I actually wanted to record this sooner, but I'm glad I didn't because I started that series about a week ago. And since then, we have taken on a client with two offices, and unfortunately, he is also a victim of embezzlement. And I just want to pause because you and I talked about this yesterday, Jen. We were talking about how we see similar behaviors, not in terms of how they embezzle, but it's almost like just based on behavior and territorialness, if that's a word, how they act when the doctor brings a third party in, and there's just this, I don't know, like peacocking of territorialness, and these people just panic. They don't want anybody touching their computer, they don't want anybody looking at the reports. And once you get into the weeds, you start to understand why, and the evidence of embezzlement becomes so apparent.

SPEAKER_03:

Yeah, their reaction is so defensive. And I mean, we've had a couple just this last week. I think in the last two weeks, you and I have had a couple that we've met with that I at one point we we just had to kind of stop because at that point we weren't getting anywhere. And you can only argue so much to a point that it's not it's not productive at that point. So I think one sign that we look for is severe defensiveness, where you are trying to backpedal your way and explain every situation. When I have all the numbers and the audit trails to be like explain this, and you can explain that, and that's how that's why they get defensive.

SPEAKER_00:

Right. And just to be clear, we are a billing company and we're very thorough at the onboarding or at the pre-analysis stage so that we can baseline our accounts. We are not an embezzlement investigation company. We hand that over to the police. But sometimes we, well, not sometimes, in all cases, we have seen enough to know when we are dealing with that situation. So this, you're right. We dealt with that office that we did an analysis on, and there was extreme defensiveness with all that, to the extent that it was just flat out, I'm not gonna do anything that you are talking about. Yeah, yep, she flat out said that. And we were like, we're just here to point out the findings and show you how to use your software correctly. And it was like, yeah, I get what you're talking about, but I'm not gonna do that. And it's so disheartening for our clients when we hear stuff like that, because we can only go so far with our help, quote unquote, in air quotes. We can only help so much to the extent where the individual that we are trying to help wants the help, if that makes sense, right?

SPEAKER_03:

Yeah, yeah. And if we're going in there, if we're doing like a baseline data poll or something like that from a software, we're gonna look at everything because we don't want to be just another billing company that comes in and then we just overhaul everything. We take it over. Like honestly, when we're looking at audit trails, we're looking at like what are your patterns? Like, who takes the money, who creates the claims, who does all of this so that we can come beside them and like hold their hand and guide them. But yeah, but it's like I'm not looking at these audit trails. I know what I can see when I'm looking for embezzlement and things like that, the signs of it. But I'm looking at it more so to get like a bird's eye view of how the office operates.

SPEAKER_00:

Exactly. And it it's just crazy to me how what we see when we do those audit trails, it's really to find coachable moments. It's the patterns that we're you and I are looking for are not the same patterns that say some a company that does embezzle investigations and that's all they do, that's they're gonna look at the audit trail differently. We are looking at it from a standpoint of is this person using the software correctly? Sadly, when we're looking at it from that standpoint, the other, you know, the good, the bad, the ugly come out.

SPEAKER_03:

Yeah, yeah, we see a lot of different things in there. And we're like, oh, this person's doing a great job making all of those notes. And at other times, we're like, What are you doing? Why are you in that patient's jar? And it like tells a story.

SPEAKER_00:

Exactly. That's that you you couldn't have said it better. It definitely tells a story. It kind of is like the bow on the on the gift, and what is that? Big red bow? Yeah, like the wrapping, yeah. Wrapping, yeah, because I really feel like a lot of individuals will they're not efficient, right? So we're looking for efficiency. We can see how many times it took you to post a payment correctly, we can see how many times the payment was deleted or corrected, and that to us is an indication that you probably need some software training. We can see how many times it took you to make that appointment. You know, so there's so many things that we can see through that, and that's why I wanted to bring that up in this final episode because we're talking about harmless mistakes that can be prevented that cost the office money that put the office at risk of you know compliant non-compliance. And they're very common, harmless mistakes. I think these are things that are just commonly taught through generational, through generation. One generation passes bad habits on to the next generation, and it creates problems down the road. So let's let's talk about these harmless mistakes that are not so harmless. The first one I want to talk about is the workaround of waiving a copay. Right. So what this is something that you know a lot of offices tell themselves that, well, we're just helping the patient out. And it is not okay to take insurance money. And I want to emphasize whether you're in or out of network, it is not okay if you are going to deposit insurance money into your business checking account, you must charge the patient their portion or inform the insurance company that you had no intention to collect the patient portion so that the insurance company has an opportunity to give themselves that discount. But I find a lot of offices will give the patient that discount, right? And tell themselves they're helping out the patient.

SPEAKER_03:

Yeah. And what I see too that becomes a problem is it's their best friend or it's their neighbor or it's somebody else, but or it's their employee. Yeah, or it's their employee, and you're not, you don't have a universal financial plan for that. They if they cherry pick who the discounts are for, that can get really dangerous.

SPEAKER_00:

Well, I think a lot of offices document this non-compliance and put themselves at risk also. I see this in employee handbooks, where they will literally document that if you have PPO insurance, they and you'll get an employee discount. You won't have to pay your copay. That's not okay.

SPEAKER_03:

It's a red flag that you wrote down yourself.

SPEAKER_00:

You basically put yourself, put yourself out there and you're stating that you are not, you're kind of like that girl we just spoke to that said, Yeah, I'm not gonna do that.

SPEAKER_01:

Yeah, yeah, I'm not gonna do that. I'm gonna be some personal choice.

SPEAKER_00:

Yeah. So if somebody has PPO insurance, you got to charge them their co-pays. If something is denied, let's say due to frequency, you got to charge the patient. So these are things that I find offices are commonly creating these workarounds. I also had an office that called me and asked me, is it okay for us to accept insurance money for x-rays when the patient when they're covered, but when they are denied due to frequency, because we don't have time to check. So when they're denied, we just write that off. So talk to me a little bit about that. Like, what do you feel about that?

SPEAKER_03:

Yeah, I mean, I think there's a little bit of, I guess it depends on why. Like, so why are they taking the x-rays? If it's a routine issue, that's an office issue, that's a front-end issue that you're not checking, you're not verifying, you're losing a lot of money, not just compliance, but like money off of that too. You know, we look at numbers all day, so I always think about that. But also, you know, we've talked about working x-rays before, where like post-SRP, crowns, things like that. A lot of offices are like trying to charge for that. So that's the other end of it, where they're trying to charge for x-rays that are just for a crown seat or post-SRP. And it's like, no, that's part of the procedure. That is something that needs to be considered part of that procedure in order for you to do a good job for the patient.

SPEAKER_00:

So yeah, yeah. There's a distinct, I think a lot of people, that's a great point to bring up. There's a lot of people that are not, they don't understand the difference between a working x-ray and an a diagnostic x ray for diagnostic purposes. And you're right, if it's for like a recall routine, that's different. But I think in this case, they were speaking about all new patients. So, in other words, like we do doctor does a FMX, a CVCT, and all the things, and whether it's covered or not, we never charge the patient.

SPEAKER_03:

Yeah, I disagree with that completely.

SPEAKER_00:

Yeah.

SPEAKER_03:

Yeah, charge the patient if you need to do it, and if it's the doctor's standard of care and it's not covered for some reason, then it needs to be charged to the patient. Absolutely.

SPEAKER_00:

Why do you think offices have such a hard time with this one? Because this is very common. I mean, I I've just had a conversation with one of my billers, and shout out to Scarlett. She was bringing to my attention that one of her offices is losing about$10,000 to$15,000 a month in frequency issues. So in this case, this office is losing$10,000 to$15,000. And I actually saw the report. She she literally has a spreadsheet and she's quantifying how much the office is losing, which by the way, you guys, this is such this is one of those things that an exceptional biller will do is when they see a pattern, they will start quantifying. They will start documenting and saying, Hey, you know, I want to point out this red flag, but let me show you the numbers, let me show you the pattern. Like she has it, she has it in a spreadsheet by patient, and then how much was denied. Literally, these are appointments that are being denied due to frequency, because they're scheduling the apart the appointments two days early, a week early before the patient is actually due for recall and the cleaning's getting denied, or the x-rays are getting denied. But in either case, their chart prep system is broke, right? Because nobody's checking frequency, or the person who's handling scheduling these patients for recall is not adequately sketch, adequately scheduling these appointments. So in turn, the office is literally losing. I've seen it, I've seen the EOBs. Yeah, one month ten thousand dollars. The next month was fifteen thousand dollars. And either harmless to what would you say? Because they're not harmless, but you don't feel this, right? Like I always say these dollars don't even make it to the profit and loss, right? They're just not even making it, that they're just being lost.

SPEAKER_03:

Yeah. Well, you don't feel$10,000, but you feel$120. Yep. So if you're thinking about over the course of a year, that's a lot of money. That's several salaries, you know, that could have been paid for just by charging for x-rays. So I look at it kind of from like a three-point standpoint. I think verification, there's a gap there. You know, that should have been caught from that very first intake touch point. Secondly, the scheduler and route flip front office should have also caught that when they were doing their checks. And then thirdly, the hygienist. If it was in the hygiene schedule, that should have also been caught that it's every six months. Oh, they're a little bit early. Let's make sure. And the x-rays, especially, should have been caught that it's only under a certain amount of time frame. So I feel like, you know, when it comes to these issues, there's so much that goes on, but initially it's all on the front end that we're we're missing this opportunity. And we're not saying you're missing a PA, you're missing$120,000 if you want to quantify it like Scarlett did.

SPEAKER_00:

Yeah, yeah. It's a systemic problem. And at the core, it boils down to chart preparation or audit appointment auditing. And this is just one piece of that prep process, right? We call it CPP, I think you called it last night. Chart prep process. So we're gonna find that term and give you full credit for that. So we're gonna call that CPP. So your chart prep process. And you know, so that's that's really again something. That you don't feel because the office is say collecting ideally. We we see this a lot. What we saw this with one of your other offices, and it was frustrating to you, especially because that office had so much potential, and you spent a lot of time correcting, you spent a lot of time auditing, training, you tried training, you tried everything. But the the at the end of the day, and correct me if I'm wrong, this is just my perception of what happened with that office. I know you know who I'm talking about, but I feel like that doctor is so comfortable with the current income, which is a very nice income. But you and I you more than I saw so much more potential. And when you tried training that team, you were told that a vulgar word choice word that starts with the letter F that we are not gonna do that. And essentially you were asking them to document a little more clearly so that you could build for what they're actually doing. And they just didn't want to go a little further. And I think you went as far as, and this is gonna just kind of walk us into the next harmless thing, which is templates. We wanted to take some time to update templates to help them get paid, but you didn't want to run the risk of them overusing them because this is one of those offices where they everyone's just comfortable. Yeah, right. And I we see this a lot, and I I don't want this to be like a bashy. And the definition of efficiency, you guys, is to do something right with less attempts, right? So eliminating redundancies in processes and becoming more efficient, essentially getting to the point where we can get the workflow done the first time around, as opposed to having rework and and so many redundancies. So, Jen, why don't you talk to us a little bit more about templates and how you feel about this?

SPEAKER_03:

Yeah. So with that particular office, it was a couple things that they gave me a lot of pushback on. The first was route slips. There was just so much disconnect between the back and the front. And I, you know, I uploaded a custom templated route slip so that they could use that. And it was just not received very well between the entire office. There was no communication, no helping each other out, anything like that. So that was not received well, but that ideally would have connected those gaps, right? The next template that we tried was hygiene templates for notes. And with these, I always try to tell offices that, like, I have a template. And, you know, Erica, you know I have the hygiene coding and billing playbook that I offer on my social media accounts, has all my templates and everything in there for them. But these are meant to be a guide. It's not a verbatim word for word, every single patient gets the same thing. I see a lot of hygienists do that. They upload a template that is probably 70% of their patients or so, you know, class one, period, healthy gum tissue, pink, rolled, blunt, like it's all the same things. And then they just go in and change it where it's needed. Where I would encourage offices and providers is to change your templates to be fillable, not filled already. So it can't be patient-specific in any way. Anything that is patient specific is out of compliance, but you could say period generalized class blank, leave that open so that you go back and you make sure you put in that specific patient's information. Advise patient to blank, you know, you can have 70 to 80% of your template built out and it will have all the necessary information that you need in there. But anything specific to a patient has to be blank. It has to be fillable so that it can be like directly related to that patient. And we check that even as billers. You know, I know you check it, Scarla and I check it too. That anytime there's a note template in there, if there's blanks, I'm like, your note's not finished. And I can tell right away. And they're like, well, the note's in there. Yeah, but it's not finished. Like that's that doesn't give me a diagnosis to attach to this claim. So I need you to go finish that. So as you know, we're implementing diagnosis codes, that's another thing with these templates. Everybody uses these universal diagnosis codes when really it has to be individualized. So that's why we need that note template to be individual to that patient.

SPEAKER_00:

Yeah, absolutely. So what they're telling you is I selected a template and inserted into the clinical note, and your response is yes, but you didn't fill it out.

SPEAKER_03:

Yeah, and sometimes it's in the treatment planned note, like it's not even in the completed. Yes, yes, yes.

SPEAKER_00:

I am so glad that you brought that up because I think as offices be have continue to face the staffing shortage, it becomes easier and easier to depend on things like templates, but we cannot lose sight of compliance. We have to remember that your clinical documentation is your legal documentation, and that's why Dr. Roy Shelburne has an entire lecture around what he calls uh clinical records prevent criminal records. And I love that. For those of you that have not heard Dr. Shelburne's story, if you're in dentistry and have not heard Dr. Shelburne's story, I think that you should go seek it out. It's all over YouTube. You should go listen to it, get out from under your rock and go hear his story because he is a dentist who had weak clinical notes that could not defend him in his Medicaid investigation and ended up going to prison for 19 months and losing his dental license, and he's been through it all. So now he talks about how documentation is so important. I had the pleasure of sharing the stage with him at YM Dental Lab in 2024, and he talked about how you should even document a patient's non-compliance to a treatment plan in your clinical notes so that you have documentation in the event the patient claims that you know you didn't do your part as a provider, but they were non-compliant. They didn't show up to appointments, they weren't doing their at-home care. Document all of that in the clinical notes. So the missed appointment should get documented on the clinical side because, again, that is your legal documentation. So that was a big, that was a big piece of advice that I picked up on when we did that together. But yeah, I think templates are definitely getting overused, and we cannot use the fact that we're short staffed to make create workarounds for clinical notes. Very, very, very important. And you know, billing from a billing standpoint, clinical notes are the basis of everything we put on a claim for. You know, I cannot submit a claim, and I nor will I submit a claim without clinical notes. And and my team, everyone at every biller at Fortune knows that. You can't you if you get caught submitting a claim without clinical notes, you are not allowed to be a part of this team.

SPEAKER_03:

Yeah, you can't sit with us.

SPEAKER_00:

You can't sit with us. You can't sit with us, you cannot, and we wear pink on Wednesdays. So, you know, that I think is one of those again, those workarounds, it's been perceived harmless, but you guys, it is not it is not harmless, it's harmful. So doing that, okay. So let's talk about a biggie gen because I see this a lot. I want to talk about carryot. My favorite thing. So before we do, I I want to I want to ask you a question because I don't know why. Why are why are most hygienists afraid to have a conversation with the patient about maybe not qualifying for a Profi anymore? Or maybe they maybe they haven't, but we've just been avoiding that conversation. So maybe that's why they're not doing the periochart. I feel like those conversations are very hard for hygienist. So talk to me a little bit about that, and then and then let's talk about perio charts.

SPEAKER_03:

Yeah, that is a loaded question. I know years ago we've talked about this, I think on the podcast, but it was, it's been years. The biggest thing I think with hygienist is that, and I wouldn't say most, I would say there's a small percentage that is scared or nervous or not confident enough to discuss what the patient needs, or they just don't know how. They get intimidated by the conversation. They know their clinical data and their education, they're strong in that, but the communication comes across as confusing or abrasive or overwhelming to the patient, and they don't want that, so they avoid those conversations. The other side of that is I think there's maybe some more experienced hygienists who have had these patients a really long time, and maybe they've just gotten into kind of a rhythm. They maybe do a period, maybe, or they just quickly do a spot probe and we can tell, and don't actually notate any changes in the patient's chart. And then what's harmful is when that patient goes to another office and they get told that they have perio, but they've been seeing Betty over here for 30 years, and that's confusing to them. They always loved her, they talked about their grandkids, like all these different things. So the relationship needs to be still a clinical one, not a friendship, to the point where it's detrimental to the patient. We need to be confident in not only our education, but our verbiage and our communication to these patients that we explain these things to them throughout the entire appointment. Again, talked about this earlier, case acceptance, but there comes a point to where we need to one, acknowledge what the patient has. We need to give them clarity on what that is and gain clarity from them, you know, what's feeling hard for you right now, what what kinds of things are you feeling, what's frustrating, and kind of gain the clarity of where they're coming from. And then as hygienists, we can come in and help educate them. You know, well, if it continues down this path, do you kind of understand where your teeth could go, where your gums are going to go with that? Kind of warn and educate, and then invite them to do the treatment, whichever way we want to go. So in that conversation can be really hard, especially if you're a new hygienist or if you've had these patients for a long time. It's intimidating, it's scary, it's costly to the patient. You know, you don't want to hurt them either. They're your friends, they're whatever. So I think in general, we just need to have a better understanding of how we can prep the patient for that, what we talk about during our appointments, and help the patient understand that we have their best interest in mind, and this is for their overall health, and then get ourselves out of the way because we make assumptions a lot of the time based on what we think is hard for the patient. Maybe we think it's cost, but really like they're a millionaire and we don't even know. And it's not cost, maybe it's fear or they're terrified of needles or different things. So gaining clarity is super, super important when we're talking about case acceptance.

SPEAKER_00:

Yeah, yeah. I think that this also goes back to a form of chart prep because if we review that a chart or that appointment, right? Taking a deeper look at is this patient a regular bloody trophy patient? Like, you know, should we have, should we be prepared to have a different conversation with this patient, right? Yeah. Yeah. And that's at the past clinical notes.

SPEAKER_03:

Yeah. And that's on the hygienist. That is part of our, we should be prepping for our days. What our patients need. If we know that that patient has had bleeding in the past, we know that we kind of warned them last time that, you know, if you don't get this under control, then we're gonna have to go to the next treatment advancement. Then we already know that conversation in our head. We already understand, you know, remember what I talked to you about last time, and we can bring that conversation back. But we're not able to do that if we just go into it blindly and we're like shocked. And then it's a bait and hook for the patient, and they feel like we've never talked about this before.

SPEAKER_00:

Give me one second. I'm gonna edit this out. I have to get a tissue.

SPEAKER_02:

Okay. I know that's so nice. Okay. So I'm gonna pause just a little bit.

SPEAKER_00:

Okay, so I think that when we're talking about chart prep, do you think that that's a shared responsibility? You know, your clinical team has a portion of the chart prep. And I'm talking about the route slip. Is this something that you find should be shared?

SPEAKER_03:

The route slip itself, no. I think hygienists should have their own preparation because front office is not going to know what to look for in a hygiene note, and hygiene isn't gonna know what to look for in insurance and the financial conversation. So it does go together in a way, but it's also separate for preparation purposes.

SPEAKER_00:

I agree with that. I agree with that. Okay, so now let's talk about from a compliance standpoint what we're seeing with regards to period charts. You know, we you can always spot a period chart, and I mean you not an individual.

SPEAKER_01:

Yeah.

SPEAKER_00:

There's been so many times we've looked at period charts together, and you're like, oh, somebody just filled that out.

SPEAKER_03:

What do you think about it? Yeah, I mean, you can go back to the audit trail. Yeah, yeah, you can go back to the audit trail and it's done in 30 seconds. I can guarantee you they didn't do that. You know, so yeah, there's there's things that we look for, you know, when we're going through these baseline data. And one of them is I look at perio charts. I look at how accurate, how often you do period charts because as a biller, I need to know that. I need to know that I'm gonna have a period chart to bill and attach to these claims that require one. Also, how am I supposed to extract a diagnosis if I don't have a period chart? It's really, really difficult. And also medical necessity, there's things tracking over time how the patient's progressing. If I only have a period chart from 2016, I can't do anything with that. It's like they never had one. So I need to I explain that to my clients and to you know, your clients that I work with you, that we have to have a perio chart. I will not fill it. It's the same to me as not having a clinical note because you have no documentation. It's just your word versus, you know, in the x-rays, people they always tell me that, well, you can see the bone loss on the x-rays, yeah, but you can't see the gum tissue. So how do you see the complete picture? And that's what the perio chart gives us is the gum tissue and the health of the gum tissue. X-rays give us the bone, yes, but the perio chart gives us the tissue health.

SPEAKER_00:

Right.

SPEAKER_03:

Yes, yes.

SPEAKER_00:

Also, kind of side note with AI processing our claims now, AI is not subjective, friends. AI was taught to follow a certain process, and having a perio chart is included in that. So, no period chart, you don't get to go past the start because it's gonna reject it. But my fear is that I've seen offices that will allow the biller to just create the period chart.

SPEAKER_03:

Yeah, yeah, which is super illegal.

SPEAKER_00:

Yeah, we we don't want to cross that line. I think that that's something you got. Please don't do that. I mean, if you can't put it on your resume, then yeah, yeah. Just just don't do it. Yeah, just don't do it.

SPEAKER_03:

That is really dangerous. And you know, coming from a hygiene perspective and a billing perspective, like I feel like my brain is always split. Like I have my pillar and I have my hygienist on one on one shoulder. But like billing side, I'm like, yikes, that's really scary. You don't actually know the numbers that you're putting in there. Hygiene side, I'm like, that poor patient. I don't actually know what I need to treat for them. You know, and so I don't know if they're healthy. I don't know if they need treatment that's just getting ignored this entire time. So that's also scary for me, too, because I I care about the patient and how they're going to be taken care of.

SPEAKER_00:

Yeah. So let's say you're a new hygienist in an office and you're looking, you're doing proper chart prep, right? Like you're looking at your account and you're going, wait a minute. These stereo charts don't make sense. Right. You know, that's probably an uncomfortable conversation to have, you know, because you're coming on board and you want to do things right, and you're realizing this office has a ton of shortcuts and workarounds, and you don't want to partake in that. So, you know, that's just that's a very uncomfortable. So that would be something that I would say maybe go look for another office.

SPEAKER_03:

Yeah, I'd say run for the hills. I wouldn't say look for another office. That is yeah. There as soon as possible. Go on your lunch and never come back.

SPEAKER_00:

Go to your lunch. That's so funny. Okay, so I I I love that. I love that that be it's still such a problem that we continue to have that conversation behind the scenes on the podcast. I mean, we're still talking about it with offices, saying you can't make up your own numbers on a perio chart. So the other thing that I see, and I just experienced this with an office, is when we have an associate on board, and the associate is seeing, let's say, the Delta Dental patient, they're not credentialed, they're not recognized at this office. So we bill under the owner. So my thoughts are stop, stop doing that first of all. But I get so much pushback on this, and we won't bill. We will flat out not submit that claim because that's not something we want to get involved with. But also have you experienced that? Like what what are your what are your thoughts around that?

SPEAKER_03:

Well, I do think that the rendering provider needs to be the one on the claim form as the rendering provider there. You know, offices will bill under the office, whatever, that's fine. If it's under the dentist's name and that's what we're billing as for the type two, then fine as the billing provider. But when it comes to the rendering provider, being open with the insurance company on who the rendering provider was is required. Like that's a that's a no-brainer for me, too.

SPEAKER_00:

It is a no-brainer for us, but it's not so common. Um, I want I want everyone to hear this very loud and clear that the insurance companies are going to process that claim under the rendering provider's NPI number. So if it's an associate that is not credentialed and contracted at your location, I'm sorry, not I I want to say not credentialed, contracted at your location, right? Because they could be credentialed and on file with that plan, but not added to the contract at your location, you will not get paid, right? So, like Delta will not pay if the rendering provider is not contracted, added to the contract at your location, even though they are credentialed with Delta, right? So I hope that makes sense to everyone. And that runs the risk of Delta denying that claim.

SPEAKER_03:

And I guess yeah, and it's a simple form. And I think that's what's that's what's frustrating to me is I'm like, why? Like, is that's just lazy management to where like every provider, whether they leave or they come, should be added to a contract, taken off of a contract as the effective date. So, you know, if they leave December 31st and we notify the insurance company this contract, this provider is no longer working here, they're taking off, they're taking off your contract as of 2012 31. You know, if we're adding a new provider, you know, there's several weeks of paperwork and onboarding and different things like that. And or you just wait until the patient is, until that provider is contracted with that group. If it's not yet, they see it the other con the other dentist that is. And that keeps you in compliance. Again, this comes down to chart prep. This is where you need to know what provider is in network with each insurance company so that you can accurately schedule that with the right provider because that gets messy really fast. But it's a very simple form, you guys.

SPEAKER_00:

I think part, I think one of the things that's important as and this, I'm speaking to my office managers. One of the things that I always did when I was managing group practices is I always had a participate, a participation status spreadsheet for each associate. And it was part of our onboarding process so that we knew in advance who they're already credentialed with, because credentialing is different from contracting. And I think a lot of those two terms get thrown around a lot, like interchangeably, as if they're the same thing, and they are not the same thing. So credentialing is be is submitting your qualifying documentation so that the insurance company knows who you are, they recognize you as a provider, right? And contracting is agreeing to those terms, like you're going in contract with the plan. So that's where fee schedule negotiation comes into play and things like that, because that's the contract negotiations. So those are two different things. So you're first gonna get credentialed, then you're gonna go into the contracting process. And I think when you're adding an associate, you're not credentialing the associate, you're adding them to the existing contract. So that, like you said, it's frustrating because it's just a piece of paper. If they're already credentialed with the plan, if they are, yeah. Right. If they're not, but you if you have a participation network spreadsheet or something that you can keep track of their participation status annually, I think that will make our jobs a lot easier. Especially for me as a third party, and I know for you as well, Jen, for us, it's important that the office has one. And I can tell you almost 100% of the time, and I know you know this, they don't have it. So we end up having to do this participation status, networking, and all of get finding all of the different plans that they're in network with because it's important for us as a building company.

SPEAKER_03:

Yeah, I have one too that I use. It's a template. I could even give it to you for the show notes for this if you want to send it out to your listeners. But it's just a blank template. The first page, the first sheet on Google Sheets is the credentialing information. So this is when their license was issued, when it expires, so that I can keep an update of that and get their new license information, like their CAQH information, maybe their social if I need it, their date of birth, their middle name, like all those little details that I just don't have time to go look for on a day-to-day basis. Then the second sheet is their network participation status. So this has all the insurance companies and then listed off as all of the providers, and then when they were deactivated, and then when their recredentialing date is, too, with all of those insurance companies. I track this like a hawk when I'm looking at everything because I've seen some billing companies that miss credentialing dates or different things like that, and you drop a contract, and it if you miss a recredentialing date, it's 90 more days to get recredentialed that you're at a network now. So it's crucial. Yeah, if you're lucky. And they don't backdate it typically. And so it's super important to keep track of that stuff. And then the last sheet I have on my sheet is just like um just the insurance companies and if the provider's a network or not. So there's a lot of information on there, but every office manager should have that.

SPEAKER_00:

Like I just should Yeah, I mean, I'm I I don't think this is commonly talked about at CE workshops, specifically to billers, you know, office managers. I encourage all billers, I mean, a biller at minimum should have this information, should have a spreadsheet. I've worked with a few billers that have it, you being one of them. And I've worked with billers that have no idea what I'm talking about. And so this is what I'm talking about when, you know, and I don't mean to go off on a different topic, but I mean there there's a difference between a basic biller, somebody who knows how to submit a claim and knows how to do basic coding, when and then you have the more advanced types that think deeper, you know, they go deeper, they go into network participation status, they go into you know, keeping track of contract dates, they go into all of the billing department because I'm a like a business, and this is running the show like a business. So don't manage to make it sound all woo-woo, you know, like I'm not trying to to do that, but I mean I do take this stuff serious because it matters.

SPEAKER_03:

Yeah, it matters for compliance, it really does.

SPEAKER_00:

It really does, and that's what we're here to do. We're here to be that element to the practice that is the compliance catch-all, right?

SPEAKER_03:

Yeah.

SPEAKER_00:

So I I really wish that more offices were exposed to stuff like this, but unfortunately, because we still don't have a formal training around billing. I mean, I have a training and it doesn't even go that deep on network participation status and and all of that, because I'm I have individuals who have no background in dentistry and I'm just trying to get them up to speed with coding and you know, things like that. But there's still no formal curriculum around all of this how to run a billing department, how to run a practice. You know, that's you're running a corporation. You know, we've got these dental assistants and hygienists who are then turned into office managers and you know, they're coming from a clinical clinical background now running a corporation, right? So there's a lot that they need to learn. I think if they were to focus on really understanding compliance, they would be in much better shape because then they would understand on a deeper level that office management is not just managing breaks and lunches.

SPEAKER_03:

Yeah. Yeah, it goes so much deeper than that. And the come I think that's something people don't realize with third parties, too, is that we see we see the big picture to where you know you have your office staff and you think they're great and it's awesome and everything's running smoothly, so you think, and then some kind of hiccup comes in where you're like, that just doesn't feel right. And then you call somebody and then they find all of these things. So a lot of times I always say this, but you don't know what you don't know until you do. And we see yep. And so we see everything. So we look for everything when we come in and we do these audit trails and we, you know, I look at notes and I look at period charts, like we look at everything, and then we give you some data that says, okay, these are your, you know, weak points of your practice. This is what we've seen other offices do that work really well for them. But what it comes down to is checks and balances. Like you have to have systems in place to where you know what to be expected of your staff every day. And you know exactly what they're going to be collecting, you know exactly what your production should be as the providers, and all of that comes into play and then kind of wraps up at the end of the day and into a pretty little bow that you can then take.

SPEAKER_00:

Oh, I love that. I absolutely love that. And I just want to point out here, that's why going back to PereauCharts. I this is why on a customized route flip, I like if you look at the one that's it's in the chart prep checklist, end of J checklist that I have in the show notes, and I want to talk about yours as well.

unknown:

Yes.

SPEAKER_00:

So I literally have on there perio chart needed today. Because it is if if we look through the the hygienist does their chart prep process, right? If you look at the blast perio chart and it's not adequate, then we're gonna request one today. And then the end day checklist, we're gonna make sure that we got it. Right? So yin and yang. So you have um, let's talk about what you have because you have your checklists, you have everything that you have created is brilliant, by the way. And it's very specific to hygiene. So why don't you talk about your your trainings, where they can go and get a copy of the hygiene playbook? Or I'm sure I'm butchering it, Jim. So I'm just gonna let you know.

SPEAKER_03:

You're okay. I know they're like so long. So I have a couple different things. The first thing that I offer just for free is periodiagnosis guide. So this gives you all the most common period ICD 10 diagnosis codes that you can have for free in your op so you know what to reference when you're looking at different things, or billers can take that too and just get that downloaded. The next thing that I've created is a hygiene coding and billing playbook. So this is primarily for providers. Front office could use it too, but primarily for hygienists. Kind of the difference between, you know, legally and compliance-wise, what is the difference between 4346, 110, alternating 49, 10, and one and 1110? What are the implications of that? So, what do we need in order to have 4341 and 4342 billable? What are some adjunct therapies that we can add in with this that we're already doing, that we're notating, that we're not billing for? So a couple of those things. And then, you know, the biggest thing that I get the most questions about is case acceptance. So, how can we help move the patient from a Profi patient to a SRP patient? And how do we keep them there in a way that still feels good and not pushy? Doesn't feel like a bait and, you know, bait and switch type of deal where they just are being pulled for money. The patient really feels taken care of. Like, how does all of that come together? So, in that one, I have a lot of scripts and pushback arguments that maybe we could work with work through. So those are primarily things like now. Um, I do have an Instagram that's running called Hygiene Unlocked. If you want to follow that, I share a lot of billing tips on there, a lot for free. That's part of the playbook, but you get a lot of tidbits there too.

SPEAKER_00:

Oh, yeah, definitely. So let me ask you this. Do you think, and is it your opinion, that hygienists just make up their mind for the patient that you know that they're gonna feel like this is a money grab because now maybe they've been coming in for a bloody trophy and we know better, so we have to do better, right? So now we have to have that scary conversation. How do I even start this conversation with the patient of mine that's been coming in for the last 10 years? And now I'm gonna tell them, hey, you have stereotypes.

SPEAKER_03:

I think the first thing is to put it back on the patient. So, you know, when you're scaling and you're probing and there's bleeding, you know, there's conversations that need to happen, like, you know, did you notice there's a lot of bleeding up there? Is that uncomfortable? You know, like reminding them this is their mouth, their responsibility on the x-rays, you notate what you see while you're taking them. You know, it looks like there's more calculus there than usual, comparing back to the previous period. Oh, that was a three. Now it jumped to a five. Is there anything different that you're doing? Like explaining and asking questions. You know, is there any changes in your medical history that it could have contributed to more bleeding, more irritation in your gum tissue? This is just really odd for you. And then they kind of reflect and they're able to discuss and think and process through that, you know, while you're cleaning. And a lot of times people be like, no, and then I'll be like, huh, that's really interesting. And then I'll ask them another question, you know, a little bit later. And it just gets their mind to process. We want them to think about this. Like, this is not our fault. And I think a lot of hygienists, too, they put so much emphasis and ownership of their patient's health on themselves when we see them for two hours, maybe four hours a year, and we can't go floss their teeth for them or water pick or brush for them. So ultimately it is their responsibility, and we have to let go of that and just tell the patient what they need because that's our job.

SPEAKER_00:

So that is so good. I think you just like it's such a loaded topic, but it's so many main points right now. Like I want to go like put that on a poster and be like, we can't floss for our patients. Yeah, right. So I I agree with you. The hygienists that I work with usually take their patient's health upon themselves and decide what the patient is gonna be comfortable with, even financially. I've had offices where you know they learn about 4346 and they're like, Oh, they'll never pay for that, they'll never pay for that, but they'll pay their co-pay for a filling, or they'll come in in their new car.

SPEAKER_03:

So it's a matter of value. And if we're not creating that value throughout the appointment of what is going on in their mouth, they're never going to accept it because they're not going to take ownership of it and they don't have any clarity around it.

SPEAKER_00:

So that's that's a really good point. I I want to pause there because that is such a good point to make because you want your patients to take responsibility for what's going on in their mouth. But if they're not willing to pay for it, they're not taking responsibility, right? Like they only want to do what's covered by the insurance company. Well, yeah, this is also covered, but they don't cover it at a hundred percent. And so let's I I want to close this out with something that's a little controversial, not to us, because to us we're we're compliance girls, right? Like, so we we're kind of like, but what do you say to the offices and to the individuals who say 4346 is a trash code and insurance companies pay less than a pro fee for 4346? So why should we use it when a pro fee is covered at 100%?

SPEAKER_03:

Okay, well, that it was that logic, just to approve. Prophy on an SRP patient because it's covered at 100%. Do a filling on a crown patient because it's covered at 80 instead of 50%. Like you are not that that logic doesn't compute when you're talking about patients' health. You know, I always talk about this. You're not going to put band-aid on stitches, like something that needs stitches. So it's the same thing in dentistry. Our mouths are connected to our bodies. And whether patients believe it or not, that's true. And it is medical necessity that they get these things done for their own health. You know, our mouth is so close to our brain and our heart and everything. And it's an opening into our body. And overall wellness is going to be, you know, it's going to be to our detriment if we don't take care of it. So I think just explaining that to the patient, if somebody says 4346 is a trash code, they don't know what it's useful for and what the ADA code stands for and what it's treating.

SPEAKER_00:

Right, right. And and they're probably not the best person.

SPEAKER_02:

Did I lose you? Yeah, I lost you too.

SPEAKER_00:

Yeah. Okay. We'll have we'll have. All right. So catching, just closing out with that, I want to talk about it from a really a compliance standpoint as well. Friends, if you know that this is a gingivitis patient and you're treating gingivitis, you gotta document that and do the use the code that best describes what you're actually doing on the patient, regardless of reimbursement. Time frame. Regardless. It's regardless. So you're going to need to rethink that. And I know a lot of offices are not, that's not the most popular opinion. I get it. We Jen and I are not, we do not work for the insurance companies. So we're not, we're not advocating that that's you know fair. It's not fair, but we want to stay compliant. And that's that's really important.

SPEAKER_03:

Yeah. And how are the insurance companies ever going to pay for it if nobody ever bills it? Correct. If they think it's never being used, they're not going to increase their reimbursement for it as a more payable code. So that's my other encouragement to you is if you do bill it because you're doing that, it's going to encourage them to pay for it.

SPEAKER_00:

Yeah, absolutely. And start including it in your fee schedule negotiation processes because I find that a lot of it. And your insurance verification. Insurance verification, absolutely. You really want to be prepared for 4346 because a lot of times they do cover it at 100% at you know its own fee, which is more than a pro fee.

unknown:

Yep.

SPEAKER_00:

And we can go on and on on this topic, but I think I'm going to close it out there and uh leave you guys with that thought. And Jen, where can everybody go find you on Instagram? I know you mentioned it earlier.

SPEAKER_03:

Yep, it's hygiene unlocked. That's on Instagram and TikTok, YouTube, all of those.

SPEAKER_00:

Okay, awesome. So, you guys, if you want to continue the conversation with Jen, she's always happy to have that conversation. Go grab a copy of the what is it called, Jen? Remind me because I don't want to.

SPEAKER_03:

Yeah, the hygiene coding and billing playbook.

SPEAKER_00:

The hygiene coding and billing playbook. You guys, it's brilliant. All right, friends, I will see all of you in the next episode. Thank you, Jen, for coming back.

SPEAKER_03:

Yes, thank you.

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