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Best Advice in Dental Billing

Posted on March 12, 2018 at 8:35 PM Comments comments (7542)

As the Dental industry becomes insurance dependent in a volatile economy and rapidly changing healthcare system, offices struggle with key aspects of the financial picture: estimations of patient’s portion, collection at time of service, and patient balance recovery, if their estimation was wrong or the balance was uncollected at time of service.

With that in mind I’ve often been asked, “What advice do you feel has best helped the practices you worked with?” The answer is simple.
1) Discern the patient’s chief complaint and, no matter what other treatments they accept, make sure you address their complaint, preferably first. 2) Don’t try to be an insurance expert, avoid “down to the penny” estimations.
3) Avoid reliance on insurance coverage to obtain treatment plan acceptance. Charge a fee before proceeding with treatment and ask for that fee at the time of service.

So how do you do this? Most practices feel that if they don’t estimate the insurance portion, the patient will not proceed with treatment. The patient will think the office is incompetent and will leave the practice dissatisfied or write a bad review.

Why shouldn’t you be the insurance expert that estimates down to the penny? The main reason is that there are too many variables to account for. Insurance fees change constantly and without notice; employers change their plan coverage without notice; insurance may dispute the provider’s diagnosis and medical necessity, and deny coverage. Even the preauthorizations you obtain is not a guarantee of payment and a small disclaimer on the bottom of the form states it clearly "this estimation is not a guarantee of payment".

As a result, you CANNOT guarantee that the insurance portion will be what you think it should be. Even with a sound benefits verification protocol, issues arise causing appeals, delay in payment, and reduced cash flow. This definitely contributes to dissatisfaction among your patient base. Any successful business needs a steady revenue stream. Anytime you buy a product or service, you must pay when you receive it, or take a loan out to pay over time. In the healthcare industry, patients want the service, but do not necessarily pay for it up front. They feel the responsibility lies with the insurance benefits they pay for. But insurance companies are in business to make money, and it is not to their advantage to pay, so they use creative tactics to delay payment and fight the provider. The longer they hold onto money, the better it is for them.

Patients must actively participate in the coverage of treatment in order to take the fullest responsibility for their own wellbeing, which payment promotes. One way is to pay as they go and as treatment is rendered. You are not asking for the ENTIRE amount. You are asking for a fee to get started, then the insurance will play their game and leave a balance or credit on the patient’s account. This is not unreasonable. To promote cash flow, the patient must pay something at time of service except in the case of 100% hygiene coverage by insurance. Here is an example of a statement that changes practices, business-of-care philosophy, and makes offices more successful: Example Treatment Plan Dental practice fee: $1000 Allowable fee: $800 Patient portion: $350 as it shows in the computer from previous EOB entries or fee schedule and plan setup. You can tell the patient: “The total fee is $1000, but with your coverage and in-network discount the overall cost is really only $800. You pay $350 at time of service to get treatment started, and we will resolve the balance when the insurance claim is paid. There could be a credit or a small balance due.”

Let’s revisit the statements made at the beginning of this article and how the statement above applies.
1) Discern the patient’s chief complaint and, no matter what other treatments they accept, make sure you address their complaint, preferably first. When you address a patient’s chief complaint, they feel heard, they are grateful, and will be more willing to pay as instructed once you set the rule that, ‘They pay $350 to proceed with the treatment and we will resolve the balance when the insurance claim is paid.’ If you try to push a patient into treatment that they do not necessarily value, you will always lose: you lose trust, lose money, and lose a patient. People pay for what they want, not what they need. Once you ear their trust, the patient will proceed with the rest.

2) Don’t try to be an insurance expert, avoid “down to the penny” estimations. Patients do not hear ‘estimated portion.’ What they hear is that they paid what you asked them when you estimated the insurance. Instead we explain that we need a portion of their balance to move forward with treatment, with the rest to be collected after the insurance pays their share. In other words, you are telling them that they are splitting their portion into two payments, which is in their favor, since you are not asking the ENTIRE portion today. This positions your fee collection policy as a benefit. After all, you cannot be responsible for what insurance will reimburse, so you must focus on what the patient needs to do with their financial responsibility. If the patient asks what the insurance will cover, you can say, “We will see after the claim resolves. It is difficult to know exactly because plans change mid-year and employers change coverage without notice. Most insurance pays 100% for preventative care, 80% for basic and 50% for major procedures. It may take your insurance company time to settle the claim, so we ask for a portion to get started and we will wait for the rest.” Your estimation is usually pretty close if not more than the expected portion.

3) Avoid reliance on insurance coverage to obtain treatment plan acceptance. Charge a fee before proceeding with treatment and ask for that fee at the time of service. When you focus on the insurance portion estimates and you cannot provide this information, you end up sending a preauthorization and delaying treatment. By asking for a portion up front you can begin right away. Focus on the patient’s chief complaint or whatever issue you diagnosed. The patient needs to come to terms with the fact that the problem must be fixed, so help them do so; don’t hide behind insurance estimations or preauthorization to delay treatment due to fear or finances. A portion of the allowable fee to get started is not too much to ask for when you tell a patient that the fee is $1000, and they are getting a discount of $200, the insurance will pay 50-80%, and their portion is $350 to get started. You must work through those numbers to inform the patient. It starts with $1000 and is reduced to $350. Not a bad deal! In our practices we actually eliminated the estimations and Blue Book history and set a price to collect at time of service for all basic and major procedures; basic was $75 and major was $400. We came up with these fees based on the average insurance reimbursements, but slightly higher; most insurances may pay $350 for crowns so we raised the fee to $400 to cover the downgrades plus other exclusions and denials. Once the patient has a credit on the account, let’s say a core procedure is denied; now you have a partial payment towards the not covered core when the patient owes more money. Working up a financial agreement with a patient, then collecting nothing from them at the time of service, is huge loss and sends the wrong message: that patients can sign all the documents you put in front of them but can pay you when they want to. This is how accounts receivable rises in your office.

Try this with a few of your patients and see how it works. Your confidence will set the tone for acceptance or effective handling of issues. In your conversation you want to communicate the struggles providers have with insurance companies and that this is the best solution to proceed with treatment which the patient needs. In our practices we review with the team, during the morning huddle, what we expect to collect that day from each patient. On the next day we report how much was actually collected, why, and what provision was made to recover any unpaid revenue. We go over the actions taken and create a column in the schedule dedicated to all follow-ups for the entire team. For example, you can create an appointment to follow-up on a patient reminder for pre-med, or call the patient to obtain credit card payment if they did not pay at time of service, or to reschedule a broken appointment. This is very useful. All tasks MUST be cleared by the end of the day by the person who created each one. And if they were not cleared, they are moved to the next day until they are handled. Hope this helps! And let the revenue flow!

Dr. Dorothy Kassab 3649 Erie Blvd East, Unit10 Dewitt, NY 13214 800-652-3431 [email protected]

Simply Overlooked Task-Electronic Claim Submission

Posted on March 12, 2018 at 8:30 PM Comments comments (4525)

One of the most important tasks in dental billing, to ensure fast insurance payment, is the claim submission. You are probably thinking it is the easiest task and takes no time. But that's exactly it! If it takes you no time you are probably missing something. Let me explain. The claim submission task is a 4 part process.
1) all completed procedures must have a claim created and batched
2) specific procedures must have supporting documentation to obtain payment
3) rejected claims must be corrected and resubmitted
4) the electronic remittance advice has to be reviewed and managed to clear the report

Creating Claims for all completed procedures
For some reason, teams somehow miss creating claims at checkout and sending them for batch processing. What happens, is that the claim never goes out and doesn't really appear on any aging reports that are commonly worked. One place you will pick it up, is the patient balances. Since the claim never went out, the balance is assigned to the patient. If you do not consistently work your patient balances you might overlook this and pass the claim's timely filing. Then, you get an angry patient. Each dental software is different, in some softwares there is a separate report that lists all the procedures without claims attached to them for patients with insurance. If not, you will have to count on picking this up when you work the patient balances. Therefore, team needs to pay attention that a claim is created for the appointment at checkout and batched.

Supporting Documents for Dental Procedures
Nothing is more annoying to your front office team than submitting a claim for a crown and not having an x-ray required to submit with the claim or a missing diagnosis for a narrative. Or submitting for scaling and root planning and not having perio charting to accompany your claim. A claim without supporting attachments is delayed and in the batch processor as rejected. Most dental softwares have an automatic setting to prompt for the supporting documents with certain ADA codes. Your front office will then need to ask the clinical team to either bring the patient back or basically submit the claim without the information knowing that payment will be delayed or denied. On the other hand, many offices have the documents, but do not pay attention to this step. Or their software is not setup to prompt for documents on specific ADA codes. That is sloppy billing, increases your AR, and decreases your cash flow. If you do dental billing long enough you know exactly what information needs to go with claims to expedite the payment. Look into this important setup in your software. Ask what codes prompt attachments and make sure this is setup correctly.

Managing Rejected Claims
After you hit the submit button, you need to check the submission report. It will show you the unsubmitted claims due to rejections. We tell the offices to track the number of rejected claims in one week to see what their submission success rate is and what their rejection rate is. The rejection rate should be less than 5%. A claim gets rejected for one reason: the information that the insurance has does not match what the provider is submitting. That means that your insurance setup for that patient is incorrect, patient or subscriber demographics are incorrect, or the provider information is incorrect. Every single rejection must be corrected. Many offices do not take the time to resolve this report. What will happen is the claim will not be on file and will need to be resubmitted at some point. So why not do it at the time of original claim submission? You may have to call the patient or the insurance company to verify the insurance, patient's demographics, the subscriber demographics, or provider demographics. It boils down to the insurance verification process and insurance setup when the patient is first establishing or when they provide you with insurance changes. Does your office verify benefits? What information does your office gather when the patient arrives? Does your office know how to properly setup the patients and their insurance in your system? Do they understand the coordination of benefits and birthday rules for dual insurance assignments?

Electronic Remittance Advice Management
You are not done yet! Everyday, your e-claim submission software should have the ERA reporting directly from insurance companies. If it doesn't, see if you can sign up for that service. Let me explain the importance of this. The insurance companies report back to your software that they received your claim, give you a claim number, and they tell you if they need any additional information, they send you EOBs on payments, they send you denials, and preauthorizations. This is a very useful tool for claim correction and resubmission, obtaining EOBs or EFTs, scheduling treatment off of pre-authorizations, and initiating appeals on denials. Most insurance companies send this ERA information within 2 weeks of claim submission. That is 2-3 weeks earlier than snail mail. It is also an electronic paper trail record. It will save you hours on the phone and speed up payment. Now you are done with the claim submission task. I call it pay-it-forward, spend the time in the front end so you will not need to spend time on these claims in 30 days. And that is because unresolved claims will get paid within 30 days and will not show up on your claims aging report. Hope this Helps!

Dr. Dorothy Kassab
3649 Erie Blvd East, Unit10 Dewitt, NY 13214

Claims Not On File After Submission-Big Struggle with Insurances

Posted on August 21, 2017 at 2:10 PM Comments comments (1556)

Electronic claim submission is amazing and provides a tracking mechanism for claim submission.  However, many insurances are still non participating in the electronic payer process.  In fact, it probably works to their benefit to keep it that way so they can delay claim payment.

The most frustrating aspect of dental billing is the "claim not on file" claim status.  We work diligently to send clean claims and when the claim is unresolved for over 30 days, we call the insurance company to find out why the claim has not paid.  It is the most annoying answer that our specialists hear from the insurance reps-"Your claim is not on file".  

What do we do then?  This often happens with claims that are mailed due to the insurance being a non electronic payer. The mailed claim is always "lost" somehow.  The first thing that needs to be done is the patient's demographics and the office demographics must be verified with what insurance has on file with the subscriber and the provider.  Request the claim be faxed to a supervisor.  Do not hang up until the fax is received or you get a supervisor's contact information.  If supporting documentation is necessary especially xrays, the fax will not work since the xrays are non diagnostic off of a fax transmission.  But that is ok, first get the claim on file via fax, to avoid timely filing issues, then you can follow up in a few days and submit the supporting documentation via mail certified mail to the supervisor.

Interesting Dental Billing Tips

Posted on April 25, 2017 at 10:50 AM Comments comments (6796)

Medical & Dental Billing News


For insurances that have a long wait on hold to speak to a representative, try calling the patient line instead of the provider line. Then, ask to be transfered to the provider extension. Your wait should be significantly decreased. Also, find out what the hours are for provider line and patient line. We have found that the patient line is opened 1 hour earlier than the provider line, giving you the opportunity to get right to a representative.


For patients with dual insurance, in a situation where there is a dental rider on a primary medical plan, you can submit to both, primary and secondary, on the same day. This is because the secondary dental insurance has the allowance table of the primary insurance and can configure what the dental rider on the medical plan will pay. Sending both claims at the same time will decrease your time waiting for both payments. Normally, you have to wait for the primary EOB and send it in with the secondary insurance claim. In this situation, the secondary insurance does not need to see the primary EOB because they can estimate what the primary will pay. Therefore, the secondary insurance proceeds to process the claim without the primary insurance EOB.


Pearl of the day: When submitting corrected claims for procedures, make sure to put the original claim # on the corrected claim so it is not reprocessed as a duplicate. If the insurance determines a claim to be a duplicate, and does not recognize that it is a corrected claim, they pay nothing and do nothing. Therefore, all efforts, requested additional submitted information, is ignored, delaying payment. It is the insurance companie's tactic to delay payment. Ask how we know.



When asking for patient's name, make sure to ask the patient how their name is filed with the insurance company. If claim is ANY DIFFERENT i.e. how it is spelled or hyphenated they will not process the claim. Has to be exact.


When taking a Pano and Bitewings on same day --- Insurance may give you the most comprehensive benefit applied. Which means they will give an alternate benefit of a FMX which has bitewings included. Therefore if the patient has reached their frequency on FMX limit - both the pano and the bitewings won’t be covered.

If the bitewings where submitted to insurance by themselves then they would be covered if eligible.

So if you submit to insurance a panoramic x-ray any other combination of x-rays, an alternate benefit may be given and could possibly be given the most comprehensive benefit (FMX) and no benefit will be paid, depending if the patient has reached their frequency limit on the FMX.


February 2017, Medicaid sent out letters to providers across the nation requesting refunds of money paid to billing companies that charge a % of collection for their services. Medicaid has determined that paying a % of collections is illegal fee-splitting. They are also charging 9% interest. Dental Claims Cleanup has always charged flat rate monthly fees for our services. READ THE ENTIRE ARTICLE located on our home page under pricing.

Dental Insurance Credentialing & RetroActive Credentialing

Posted on April 25, 2017 at 10:45 AM Comments comments (6141)

As the landscape of the Dental Industry changes, and we engage in increased insurance contracts, it is difficult for providers to repeat the credentialing process annually and remember the dates to re-credential. As a result, many providers found themselves receiving an out-of-network status notification and were dropped by the insurance. Recently, Delta Dental did a nationwide sweep of dropping providers and sending out-of-network status notices. This can be a devastating and costly mistake to the practice. When this happens, the insurance payments start going to the patient and the patients owe more money for treatment, therefore start leaving your office. You can outsource the credentialing process if

1. you want to ensure that you are in good in-network status, and

2. you would like to take the credentialing burden off of your team or yourself, or

3. you are hiring a new provider and need to enroll them in the insurances you are contracted with

4. you are interested in signing up for a new insurance, or

5. you purchased an office that you are not credentialed with the insurances the new office is in-network with

Our credentialing department uses specialized software that submits the information to the insurance companies in a professional, legible, accurate manner, ensuring the credentialing goes through fast without problems. The software communicates with the insurance companies to alert us when the re-credentialing process needs to be done. We specialize in RetroActive Re-credentialing. A most common credentialing issue is during practice transitions. The owner purchases a practice and the owner is not credentialed with the insurances the office is in-network with. Another scenario is when you hire an associate. The associate starts working but is not credentialed with the insurances. Insurances pay based on the in/out-of-network status of the Dentist provider that actually did the treatment. Therefore, if the associate is not credentialed, claims are paid to the owner, on an out-of-network status. Many owners enter themselves as the providers for the treatment performed (since they are credentialed in-network), but, as we know, that is illegal. Since the process takes up to 3 months, claims are paid on an out-of-network status. If your claims did not pay due to credentialing, we will appeal the case to push for a retroactive re-credentialing. We helped many clients with retroactive re-credentialing and re-submitted claims resulting in payment.  

visit our website for more information:

Billing Medical Insurance for Dental Services

Posted on December 10, 2016 at 8:10 AM Comments comments (7166)

In response to the changes in the healthcare reimbursement plans, billing medical insurance for dental procedures is becoming a necessity. Currently, the dental industry may not be ready for billing medical insurances for dental procedures. Dental Claims Cleanup has been developing cross over systems and protocols to aid Dentists in the task of billing medical insurances for dental procedures. This article will review commonalities and differences in medical and dental billing, as well as, provide pointers in the medical billing process for dental procedures.


Medical and dental billing share the following:


Patient and insurance information has to be obtained, verified, and correctly set-up in the practice management system

Procedures must be coded and fees established

A claim form is submitted

Payment is received with and explanation of benefits (EOB) that needs to be broken down in the practice management system

claims need to be followed until payment is received and re-submission and appeals are performed until payment is reached

patient's portion must be collected after the insurance claim resolves or must be collected prior to the procedure (if an estimate of patient's portion is possible)


Differences between medical billing and dental billing:


Medical billing requires diagnostic codes to support medical necessity of procedure codes to be submitted with the claim; there is no requirement yet for diagnostic codes in dental billing, however, diagnostic reasons for dental procedures are provided upon request by the dental insurance, during narrative submission with claims, and during claim appeal process, and must be documented in the patient’s chart.

Insurance coverage depends on an exact match of plan coverage and diagnostic codes for procedure codes. Claim denial is more likely with medical claims, due to the requirements necessary for a "clean" claim submission, therefore, it is important to find out information requirements for certain procedures before the claim is submitted during the coverage verification process (pre-certification and re-authorization)

Sending "clean" claims in medical billing is crucial to obtaining coverage and payment. All information must be accurate including patient, provider, and insurance demographics, diagnostic codes and procedure codes, modifiers, narrative submission, etc.

Pre-certifications (“pre-certs”) for treatment are important prior to proceeding with treatment. Decisions are made, once pre-certs or denials are obtained, to submit to dental insurance instead. The patient can make a decision whether or not to proceed with treatment, based on the information received from the pre-certs. Other pertinent information is discovered during the pre-cert step that aid in claim submission and claim coverage based on the information disclosed in the pre-cert. The insurance company will determine whether the procedure needs to be pre-certified or pre-authorized. Pre-certifications establish that the procedure “may be” medically necessary and needs a review prior to payment. Pre-authorizations establish that the procedure will be covered, but the insurance company does not disclose any fees.

ADA codes for dental treatment encompass many procedures that are not coded, but are part of the fee (ex: lab materials, lab fee, temporary crown fabrication, visit for insert of the crown, x-ray when crown was seated etc.) Those parts of the treatment are included in one crown fee. In medical billing there is a service CPT (reports medical, surgical, & diagnostic procedures and services) or HCPCS code (products, supplies, & services not included in the CPT codes) for all the parts of treatment or a procedure which would add up to the analogous one fee in dental coding. The fee for medical treatment is obtained from coding all parts of the treatment. Dental billing bills for a “product” provided and this product has one fee that is coded. In medical billing, we bill for treatment of a “condition” provided (includes services performed based on time and complexity, products/devices, materials used and amounts, and diagnostics procedures, the procedure can be broken into technical service and professional service provided).

Medical claim submission has 90 days from day of service prior to expiration, while dental insurances allow up to 6 months, or even up to 1 year, for claim submission from date of service. Therefore, if medical insurance does not pay for the dental procedure, there is time to submit the claim to dental insurance. The claim can not ethically be submitted simultaneously to dental and medical insurance. If you submit $500 to medical for a procedure, that gets denied, you have to submit $500 to dental insurance for the same procedure. This is why, the price for the procedure, billed to dental or medical, has to be the same. Several medical codes (which will include services, products/devices, materials, and diagnostic procedures) may need to be used for the analogous ADA code, but the price for the treatment should be the same. Many ADA codes include procedures that in medical coding are billed separately. Ex: x-rays in dental billing include the diagnosis and reporting while x-rays in medical can be billed as service fee (technical component) and the reporting fee (professional component) with a modifier 26.

Narratives/letters to support medical necessity are crucial to obtain medical claim coverage; in dental billing, letters of medical necessity are only necessary for ADA codes that ask for narratives by report or during the appeal process, or as a follow-up to referring provider.

Medical reimbursement for exams/office visits/consultations depends on time spent with the patient encounters, complexity of the encounter/exam, and reimburses for each encounter for previously diagnosed condition, in dental follow-up visits and visits for previously diagnosed condition are considered part of the dental procedure.

Medical insurance does not provide fees for treatment during the benefits verification process, or pre-certification process, but rather, informs if treatment is eligible for medical billing after claim examiner review. Pre-authorization will tell you it will be covered by the plan but the insurance company will not disclose the fees. The reimbursement depends on the medical plan’s reimbursement schedule, covered benefit, and if it is a medically billable procedure. It is not possible to do a sound pre-estimate and figure out the patient’s responsibility for the treatment, therefore, the provider must decide what will be collected at time of service. If the medical insurance reports that the services will be covered (pre-authorized) and can be submitted, a minimum of 1/3 should be collected from the patient, as a down payment, at the time of service. Some medical insurances are known to take a long time to pay out. Providers might consider to collect the total amount, from the patient, at time of service, and the insurance payment is sent to the patient directly.

Most of the time, medical insurance has a higher reimbursement for dental services than dental insurance resulting in a lower patient balance. This is because several parts of one dental code are billable to medical. Payment for several more codes results in a total higher insurance reimbursement. In addition, there are no clear provisions or history for payments on dental procedures, therefore, often times the medical insurance pays well on those codes.

Dental insurance allows to charge out indirect procedures, involving a laboratory, on the day of impressions, while indirect procedures can only be billed out to medical insurance on the day of the insert.

1. How to get started? The Dentist must decide which procedures that they perform will be eligible for medical billing.

1. traumatic injury

2. inflammation or infection

3. surgery required

4. diagnosing/diagnosed medical condition

5. suffering from loss of function

6. referral from medical Doctor


2. The Dentist has to make a medical connection based on the medical history to the dental treatment that needs to be provided. A letter of medical necessity needs to be written and submitted with the claim.


3. Next, we suggest the Dentist runs a report of those medically-billable procedures, that were already treatment-planned, form the practice management software. Call the patients and obtain their medical insurance information. Inform the patient that you will attempt to check with their medical insurance for assistance with this treatment. Only when there is pre-certification, pre-authorization, the patient is scheduled. When calling the patient to schedule, make sure that at least 1/3 of the fee is discussed to be collected at time of service towards the treatment for pre-authorizations. Also, discuss the full fee for the treatment, for pre-cetifications, in the event that medical insurance does not pay at all. Have a back-up plan to submit to dental insurance and quote the patient the dental insurance breakdown based on dental insurance coverage history.


If you need help implementing medical billing in your office, please give us a call. Dental Claims Cleanup will setup your medical billing program including your medical billing software, worksheets, and train your team for $500 one time fee. Phone support service of $100/month is available. If you are interested in completely outsourcing medical billing with us, we charge a flat fee of $500/month for up to 50 claims and $10 each additional claim. Please visit our website for more information

Solution to a Problem in Every Dental Office

Posted on December 10, 2016 at 8:10 AM Comments comments (4869)

The health and wealth of a dental practice is highly dependent on accurate, efficient, and consistent dental billing. With the changing landscape of the Dental Industry, increased dependence on dental insurance, the increased debt of the young Dentists, and the gobbling up of practices by Dental Service Organizations, the private practice needs help. There is a reason why DSOs are so successful. It is because they provide a solution to the dental business management and the dental billing headache. However, not all of us private practice practitioners want to be a DSO Dentist. So what can we do in this changing Industry that will solve the headache of administration but not change our practice philosophy. Did you know that outsourcing dental billing is available to practices, without the ties of a DSOs? Dental Claims Cleanup has solved this dental billing problem with our services and we provide an alternative to a DSOs.




Here is what happens. When the office losses an employee to disability, medical leave or pregnancy leave, or does not have the manpower to plow through the dental billing workload, or if the team is lacking skills, or the Dentist does not have the ability to supervise the dental billing and accounting, the Dentist is left vulnerable. They are at the mercy of local talent to hire, train, and hope that the new employee will honest, self-motivated, and skilled to run the financial aspect of the practice. After a few hires and fires, and a progression into increased accounts receivable, the Dentist realizes that business management and dental billing is a huge headache and they start investigating options. The first one that comes to mind is partnering with a DSO. All of us are getting notices from Heartland, Aspen, and Pacific. They are successful organizations and employ many happy Dentists. The offers are very tempting, but we went into private practice for a reason, right? So if we don't want to sell the practice, don't want to partner with DSO, and do not want to pay for consultants, what options do we have?




What if you can keep all as is, but outsource the part that is a keeps you up at night?


What if, instead of you paying and supervising the employee performing the job, someone else will have that headache?


What if, instead of you paying the employee benefits, you get bothered about raises and time-off, someone else will deal with that burden for similar or lesser price?


What if you had all the help you need to take the headache away, without changing your practice philosophy or have any ties to other business organizations?


What if, in exchange, you and your team has more quality time with your patients and has more time to focus on the schedule and treatment acceptance?




Answer these questions to see how effective is your office in dental billing and business administration:


1. Claims Management (claim submission, claim follow-up, claim correction) is a job that needs to be performed every day.


a) Are your claims submitted at the end of every business day?


b) Does your team have at least 2 solid hours to follow-up on unresolved claims per day?


2. Account Receivable volume aging over 30 days: AR reports need to be run weekly. Industry standard is no more than $5,000 in over 30 days total unresolved claims and $3,000 in unpaid patient balances over 30 days for every 80,000 of monthly production. Carve out 1 hour per week to meet with the person doing your dental billing. Your team should have reports for you: a) status on ALL unresolved claims over 30 days, b) amount of unresolved claims over 30 days, c) amount of unpaid patient balances over 30 days. Keep the reports from week to week. Expect insurance payments in 3 weeks. Expect patient payments in 1 month.


a) Is your total accounts receivable over 30 days less than $10,000 for every $80,000 gross production?


3. Patient Balances: Patient co-pays MUST be collected at time of service or NO service is performed


a) Does your team collect the patient’s portion at time of service?


b) Are your total overdue patients’ balances, over 30 days, less than $10,000?


4. Insurance Verification is done 3 days prior for ALL hygiene patients. All new patients and emergency patients are verified and setup as they make the appointments. Use a benefits verification sheet to obtain plan specific clauses that match your frequent procedures. Correct plan setup is a must and the team should be trained in this area. Use an eletronic verification service that, with a click of a button, verifies patients from the schedule. It will not necessarily tell you plan breakdown, but it will tell you they have active coverage.


a) Does your team perform benefits verifications and draft treatment estimates based on verifications so they can collect the correct amount at time of service?


5. Accounting: When EOBs are entered and there is a remaining balance, call the patient after you enter the insurance check payment, and ask to resolve the balance over the phone with a credit card. If you do not reach the patient send a statement. Statements should be going out daily and at least once per week.


a) Does your office enter ALL the EOBs and ETFs, for that day, same day?


b) Does your office send statements at least once per week?


6. Financial Agreements and Treatment Estimates: Sound financial agreements must be drafted, signed by patients, and retained so that clear patient responsibility that was discussed prior to procedure is documented. The amounts to be collected, at time of service, should be reviewed with the team in the morning huddle and reviewed the following day to make sure it was actually collected. Review with the team reasons why the money was not collected. This accountability help keep employees motivated to collect at itme of service.


a) Do all of your patients, regardless of amount, have a signed financial agreement, and are they clear what their portion is at time of service?


7. Hygiene Reactivation: A full hygiene schedule ensures a full doctor’s schedule. Hygiene reactivation is a daily task. The goal is to call at least 30 patients per day, speak to at least 4, and schedule at least 4 for a single provider operation. The schedule is dynamic and must be worked every day to fill last minute openings. Unfilled appointments is money that can never be recovered.


a) Does your team work on hygiene reactivation daily?


b) Does your team track their efforts?


c) Does your team fill last minute openings successfully?




YOUR SCORE-write the number of “Yes”



#YES_________/12 x 100%=_______%



10-50% Need Help: systems not in place or lack of knowledge or man power


50%-60% Lack of Supervision or Consistency: make sure there is clearly defined system for the team to follow and get involved by reviewing reports and set accountability


60-75% Average: systems are most likely in place, motivated team, most likely time management is an issue, re-define tasks and schedule time for execution


75-85% Above Average: focus on the task the team is not executing, find out why, or define the system and expectations


85-100% Healthy Practices: owner/manager supervising and holding team accountable, reviewing weekly reports and resolving problems as they arise




Today, the entire dental billing position, and other business tasks like hygiene reactivation, can be outsourced.


Dental Claims Cleanup provides the dental billing services via a remote, HIPPA secure access connection to the dental office workstation. We seamlessly work in the background without disrupting the clinical operations. We provide the clinical team more quality time for patient care. We work with all dental practice management softwares. Our services include:


1. daily claims submission, unresolved claims research, follow-up and claim correction and re-submission with narratives or start of an appeal process


2. patient balances research, statements, phone calls to collect the balances


3. EOB, ETF entry in the dental software


4. benefits verification eligibility, full plan breakdown for new patients, emergency patients, existing patients with insurance changes, and new insurance account setup or correction as needed


5. medical billing for dental procedures


6. hygiene reactivation program: we manage all your unscheduled recalls and fill your schedule.


Dental Claims Cleanup works the accounts efficiently, producing results, and we do this for a fraction of the cost of an employees with benefits, raises, payroll taxes, and time off. We report weekly on our progress and we are the watchdog of the practice’s health and wealth. Our weekly reports inform the Dentist of trends and team’s productivity so the Dentist can make informed business decisions. We provide the resources without compromising your practice. The medical industry has been outsourcing medical billing for years because they understand that it is cost effective, efficient, and more productive. Now we have the same service available to the Dental Industry.



Anti-Theft Protection Safeguards in a Dental Office

Posted on July 31, 2016 at 6:00 PM Comments comments (4895)

I am compelled to write this article due to the number of clients that started our service this month as a result of theft in their dental office.


The subject of theft stirs something in my core. Dentists, as a group, are good, honest, people, trying to make a living. They are also the MOST vulnerable profession exposed to the potential of theft. Let me tell you why.


1. lack of training in business management leaves the owner at the mercy of others to run their accounting


2. the dental business structure does not allow for cost effective tasks distribution to prevent "one hand in all pots" which leaves one person doing all the financial aspects of the business.


3. busyness of the business leaves the owner exhausted and non-motivated to deal with the business part of the practice


As a result, the situation provides a great, tempting opportunity for theft that goes un-noticed for years and maybe never discovered. The purpose of this article is to reveal the methods of theft, set safeguards, and provide guidelines to prevent creation of an environment where theft proliferates.


Here is some examples of ways theft can occur:


1. front office asks patients to allow her to fill out/write checks for patients and instead of writing the check out to the practice, writes her name on the checks then cashes them


2. front office sets up a checking account with her name as authorized signee for check deposits. Uses this account for personal expenses


3. Front office takes cash payments for procedures and does not record transactions in the dental software


4. front office records huge discounts for cash procedures, paid in full by the patients, in the dental software and pockets the discounted amount out of the cash from daily deposits


5. front office submits lower fees than UCR and records adjustment to collection, then takes out cash from deposit to cover the overpaid amount


6. team uses business credit card for personal expenses


Here is a list of bare minimal involvement in the financial aspect of the practice by the owner Dentist, without exceptions! Starting the day after you read this article you will do the following.


a. reconcile the monthly bank statement. Bank reconciliation is a balance check for discrepancies between the daily deposits (what should have ended up in the bank) compared to your report from the practice management system. The other items that will be verified is the expenses paid with checks to vendors, as well as, any unusual transactions. For this task you will need to obtain/run the monthly deposit report from your dental software and have your bank statement available. In your Quickbooks, Quicken, or any other financial management software, you go to the reconciliation section, put in your starting and ending balances, and you check off things that were recorded throughout the month against the bank statement. This takes 5 minutes and is an easy task that even the computer illiterate can perform. The financial management software should be closed out monthly, and password protected, after your reconciliation of the bank statement.


b. review of all discounts and adjustments made throughout the month. This is another report from your dental software. The software will break out the insurance adjustments, patient discounts, and refunds. No one is authorized to provide discounts to patients other than current promotions or discounts at Doctor's discretion. All discounts must be reported on claims submitted to insurance companies, since the insurance benefit is calculated based on the fee after the discount is given. Lack of reporting of discounts is considered insurance fraud.


c. review collections report. There should be no adjustments to collections here. Any adjustments to collections should be refunds to insurance companies, refunds to financing companies, or refunds to patients. If there are adjustments to collections other than those mentioned you need to research why. A common fraud that occurs, is that the fee submitted to the insurance companies are lower than the UCR. As a result the insurance overpays. Since your dental software is waiting on payment that is lower than the insurance payment sent to you, if you record that the expected payment was received but the over-payment is adjusted (adjustment to collection), the money can be moved out of the daily cash deposit and can go unnoticed.The patient's ledger will be reconciled as $0 balance, but the over-payment can be moved via cash outside of the dental software accounting system. We have also seen this, for instance, as deceit in associate Dentist under-compensation and it is directly related to not having the updated insurance fees in the dental software. The over-payment was adjusted to collection from the Associate and credited to the owner.


d. Prevent setup of vendors in the financial management software by the same person that does the bookkeeping. Setup and editing of vendors information should be done by the Administrator/Owner or someone other than the main bookkeeper. Fraud can occur when vendors are setup with fraudulent information so that expense checks can go to that address and can be cashed by the perpetrator.


e. Review what's expected to be collected (patient's portion) in the morning and track what was actually collected to be review in the am huddle next day. This is good to track the practice collection rate, promotes the team to collect at time of service, allows for open monitoring of cash flow, is good for the health of the practice and an incentive program. Along with collection rates, production efficiency (what was booked and what showed up) and acceptance rates (what was planned and what scheduled next visit) should be tracked. The collection rate at time of service should be 97% or higher, the production efficiency should be 98% or higher, the treatment plan acceptance in hygiene should be 35% or higher, and assistants acceptance rate (treatment scheduled out of Doctors rooms) should be 45% or higher.


f. Person preparing/reviewing deposit should not be the same person who collected money all day. There should be one other person in the office that checks off on the actual deposit with their signature. If you report what should be collected at time of service in am huddle, and then a team member will review what was or was not actually collected by the front office, this will deter possible fraud. It is less likely that there will be 2 accomplices.


g. review production in the morning huddle of the previous day. Review anticipated production and actual production. Run daily reports and ask team to bring to morning huddles. This ensures that all procedures are recorded in the dental software. Fraudulent activity will be prevented if the team knows you reviewed in the huddle what you were booked to produce and review again what you actually produced. We have our providers sign off on their production. This also prevents inaccurate billing or lack of procedures that need to be billed. Many times the appointment card does not contain procedures that need to be checked out, as a result those procedures are not billed and are difficult to catch that they were not billed since the only record of the actual procedure is in the progress notes. If your office does not put procedures in the appointment card of what is scheduled you MUST start that today. Also ALL discounts to be given MUST be reflected in the appointment card. This serves as an official, authorized discount by the owner. The dental software is designed to enter the treatment plan, schedule procedures from the treatment plan (which also removes them form the treatment plan as they are scheduled), and then billed/checked out from the appointment card. Things are missed and fraud occurs when this is not followed. Something always gets omitted and it results in errors and ultimately in lack of money for the practice.


h. close out your day daily. After all transactions are entered and the deposit is balanced against production and the schedule, the day needs to be closed so no changes can be made thereafter. This is important if you are reviewing the production/collection results the next day, so you want to make sure no one can change what you just reviewed. For instance, if you review daily production procedures and now remember transactions that were part of the production, the team is less likely to remove any transactions after you reviewed and they are less likely to pocket money paid on those procedures. The day is already closed so they can not make changes to the system, so all production and collections are recorded. Too many offices do not close out the day and the team can go back and make changes to accounts. If your office does not close out the day daily you MUST start this immediately. To open up the day after it was closed, it should require a password, and needs to be done by the owner. Don't forget, the financial management software should be closed out monthly after your reconciliation of the bank statement.


i. deposits MUST be deposited in the bank daily. Once you close out the day, the money collected should be given to the bank that night in a nightly deposit envelope and dropped in a night deposit box. If you signed up for electronic transfer of funds (ETF) by the insurances, your team has to enter the EOBs same day you get a notice of ETF deposit, or the reconciliation of your bank statement will be a nightmare. Daily deposits of your money ensures:


1. easier reconciliation of deposits against your dental software since the dates will be accurate


2. prevents money laying around the office and possibly disappearing. If the team knows you will be reviewing the production and collection in the morning, fraudulent activity will most likely happen after your review. If the day is closed out, and the money is in the bank, fraud is less likely.


j. sign/review all checks to vendors. The team can prepare the checks. Al checks to be signed should have an invoice or bill paper-clipped to the check to be signed. If they enter the bill to be paid in the financial management software they need to scan the invoice or bill as an attachment to the software bill to be paid. The owner Dentist reviews the bills to be paid, signs the checks, or reviews the bills in the software, and then the OWNER pays them online through online banking. Online banking is an excellent method to handle your finances. There is a record of all checks and addresses where the checks went, you have control who has the ability to write checks and pay bills, and control who can setup new vendors. The other method of paying bills is through credit card payment. With a credit card, there is a record where the money went and ability to attach invoices or bills to each credit card payment.


k. credit card charges alert to your phone. Log into your online credit card and setup alerts (as an email or text) to go to your phone every time your credit card is used.


l. review the credit card monthly statement. Just look at it please!


In closing, your involvement in the financial aspect of the practice is crucial to prevent the opportunity of theft.


If you suspect fraud in your office or want to prevent fraud with safeguards, please reach out to us and we can assist you. The situation can be managed in several ways. We can be hired for an initial investigation or we can setup safe guards. Also, we can be the mediator with the team as the professionals instructing the practice to have the Doctor's involvement in the financial aspect (this is a good method if you are afraid the team will feel uneasy if you start asking for reports or you are doing more than you used to). Or you can outsource your billing with us. Please reach out if you need our assistance. In addition, if you were a victim of fraud, we would love to hear your story so we can see what safeguards would have prevented that from happening and learn from your unfortunate experience. Email us at [email protected]



Insurance Benefits Verification-a dreaded task by the Dental Front Office

Posted on July 19, 2016 at 4:05 PM Comments comments (3070)

One dreaded task for the dental front office is insurance benefits verification. Here are some of the issues that the front office has to deal with:


Length of time on the phone keeping front office away from live operations due to waiting for insurance reps to answer the phone and the length of the actual phone call. On average, there are 6 new full benefits verifications (new patients, emergency patients, existing patients with new insurance) that need to be obtained with an average 15 minute call time. That is 1.5 hrs on the phone.

Increased number of phone calls that have to be made to obtain full benefits breakdowns due to more frequent insurance plan changes by employers

Insurance misinformation, many insurance reps do not give the correct information causing estimation errors or wrong plan setup

Uninterrupted length of time and expertise required to enter new plans for new patients, emergency patients, or existing patients with new insurances. Once you obtain the insurance benefits verification now it takes on average another 10-15 minutes to setup the new plan in the system.

Plan clauses (exclusions and frequencies) are not considered in the practice management system. There are no fields and no provisions for this information, but the information effects correct patient portion estimation. During treatment planning, plan specific information must be applied manually and many times it is overlooked resulting in an incorrect estimation.

Plans that pay on UCR are difficult to obtain a correct estimation

Insurance fees have to be updated annually to allow for the estimation (based on the benefits verification) to accurately be computed. Updating the fee schedules for several plans takes many hours and the team has to remember to contact the insurances individually for the most updated fee schedule. We have come across insurances which refuse or make it difficult to release to the providers their updated fee schedules.

Why do we bother with this task? Because it is our obligation and it is essential to inform the patient of their treatment cost involved BEFORE they proceed with treatment. Furthermore, for the health and wealth of the practice, we should:


collect at least the patient’s portion at time of service to keep a constant cash flow into our business

not surprise the patient with a higher balance due to lack of coverage on plan exclusions or frequency limitations during our treatment estimation

know if the patient has active coverage, otherwise, the patient will be surprised with a higher unexpected balance

Financial Conflicts between patients result in 3 main issues:


the loss of a patient from the practice

an angry patient with the office or the Doctor

dissatisfaction with work performed and an excuse for the patient to refuse to pay for something they are not pleased with

Here is a protocol that is effective for dental insurance benefits verification:


All hygiene patients are verified with electronic services and phone calls if there is no e-services linked with the insurance company. We like ClaimX insurance verification software from Extradent. It is fast, accurate, cheap, and draws directly ALL patients for the day from your schedule. All new patients & existing patients with new insurance are verified by phone call and a new benefits verification sheet is filled out. The information is entered in the practice management system and the benefits verification sheet is scanned to the patient's chart. All emergency patients are verified with electronic services, if they came in for hygiene within 6 months, and with a phone call, if they did not come in for hygiene within 6 months or if their insurance is not linked with e-services verification. The verification for hygiene patients is 3 business days prior to appointment. New patients and emergency patients are verified same day the appointment was made. The insurance fee schedules are obtained in January for every insurance in contract and the system is updated. Do not proceed with treatment without a signed financial agreement and treatment plan estimation. Clear instruction is given to the patient that the patient's portion will be collected at the time of service.

Out of Control Overdue Patient Balances in Dental Billing

Posted on March 19, 2016 at 8:45 PM Comments comments (3470)

Out of Control Overdue Patient Balances Working with practices across the nation provides us with trends and common struggles in dental offices. One denominator is that many offices have the patient balances over 30 days are out of control. It is our job to clean those up, but if we do not help the practice change their protocols there will be more balances rolling over as fast as we clean them up. Here is what must happen in the to make sure that your cashflow in healthy and the accounts receivable growth is minimized. 1. Correct estimate of treatment plan with a clear financial agreement. For this to happen 2 things are pre-requisites:you must have the insurance fees update and the plan breakdown in correctly, you must verify insurance coverage and call on plan breakdown once per year. This agreement needs have the following components to specify the following: A) your total price is… B) the in-network discount for the patient is… C) the estimated insurance is…. D) the patient’s portion that needs to be collected at time of service is… E) must tell the patient that once the claim resolves, there might be more that the patient owes….. F) the insurnace estimate is not a guarantee and is base don prior hisotry of payment, the insurnace will determine what the patient willowe and what the insurnace will pay…. The agreement is signed by the patient, patient gets a copy, and scan a copy to the patient. 2. You must collect whatever the financial agreement stated at time of service. We try to collect the copay before the procedure is done. We print the scanned financial agreements and have them ready for the am huddle so we can review with the Doctors what is expected to be done today and collected today. Someone is responsible to report on prior account balances to be collected at time of service. 3. Review in the am huddle balances to collect for each patient. This should include the prior account balance and todays copay. Review the next day what was anticipated to collect yesterday and what the team actually collected. If they did not collect what was expected, the Doctor needs to know why. You might find out that you have a weak link managing your money. 4. As soon as the EOB resolves, call the patient stating that the claim resolved and the insurance determined that the patient owes______ and you are calling to collect the balance over the phone to settle the account and avoid billing. 5. Follow this collection process: a) call patient after EOB was entered to collect balances, if you don’t reach the patient b) send out balance due letter with 10 days response demand c) if you don’t hear from the patient, send 1st notice overdue balance 14 days from balance due letter. d) if you don’t hear from the patient, send final notice with a 10 day response demand 14 days after 1st notice letter. e) if you don’t hear form the patient, call the patient: You will tell them that you are calling to interfere with an automatice collection agency process. The collection agency automatically takes over overdue accounts unless they settle the balance right now with you on the phone. You certainly don’t want this matter to interfere with the patient’s dental care or relationship with the office. So you are calling as a courtesy to a long standing good patient of the office. If they don’t settle over the phone tell them to mail the check in within 3 business days. f) if you don’t hear form the patient send to collection agency and allow collection agency to follow through with their collection protocol 6. run your AR reports weekly. Review with your team responsible for billing the outstanding patient balancing over 30 days and unresolved dental claims over 30 days. This is your supervision checks and balances that the team is resolving money owed to you and that your current systems are executed and effective. Obviously if you can not supervise, then you need to outsource dental billing.

Benefits of outsourcing dental billing

Posted on November 23, 2015 at 9:55 AM Comments comments (2725)

Outsourcing dental billing is a novel concept in the Dental Industry. The fact is, that medical billing has been common practice for decades. The reason why is that medical offices have a high volume of insurance claims and need dedicated people with expertise to handle this job efficiently and effectively. It is expensive to have that team on site. As the landscape of Dentistry has changed, and the private practices increased their provider participation, the insurance claims volume increased respectively. However, there is still lack of formal education in the dental coding and billing field, since the didactic arena has not kept up with the changing trend of increased insurance providers. As a result, the dental billing remains an "on-the-job" training position. Therefore, good, but also bad, as well as lack of skills are passed on. Outsourcing dental billing has the following benefits:


1. expertise of the dental billing company gets you paid fast


2. lack of mistakes prevents angry patients


3. lack of payroll taxes and benefits saves you money


4. dental billing company does not call in sick or takes a day off of working your accounts, so you have constant flow of cash


5. professional routine reporting allows you to stay informed on health and wealth of the practice, but also provides barometers for improvement of intra- office mistakes, therefore allows for improvement. (you don't know what you don't know-with reporting on each and every claim you will know)


6. cash tied up in unresolved dental claims can have a detrimental effect on the survival of practices


7. New Dentists now have the option to be in a private practice without the knowledge of accounts management. The increasing trend of working in Corporate Dentistry is attractive to new graduates who do not have knowledge in the financial aspect of the practice. If this continues the private practice in Dentistry as we know it will cease.


Please visit our website for more information

Appointment Pre-Booking Interview

Posted on October 19, 2015 at 11:30 AM Comments comments (5044)

So here is a concept that might be new to you- "Appointment Pre-Booking Interview". This is a series of questions from your scheduling coordinator to our patients to discover if they truly should be given an appointment. What we have found is that the no shows kill practices and the financial burden that they place on the practice is unacceptable. So we researched what are the top 4 reasons that effect a patient showing up for their appointment. Research showed that they sequence from highest frequency as follows:

1. Value

2. Time

3. Fear and

4. Financial.

In response to this we developed a series of questions that the team can ask. If, and only if, the patient answers YES to all do they go into the appointment book. As the team learns this concept the sheet goes away and they can make a decision whether or not the patient should be given an appointment. Here is the link from our website

In addition remember that we recommend 1/3 down of patient's portion for large procedures to be placed in the appointment book and 3% or 5% discount for total pre-payment.

Charge full fee on not covered procedures by dental insurance in certain states

Posted on October 17, 2015 at 5:10 PM Comments comments (8697)

from website:




Lawmakers in several states have passed new legislation that no longer allows insurers to require dental providers to give discounts for services not covered under an insured dental plan. Listed below are the states that have passed this legislation and links to the actual laws.


We encourage policyholders to share this news with their plan members who may obtain services from dental providers in these states. While this new legislation applies only to discounts on non-covered services under insured plans, and does not affect the policyholder's current insured benefit plan(s), members in these states may no longer receive discounts on non-covered services and should discuss any available discounts with their dental provider.


As the legislation continues to progress in other states, please check back for any updates, especially for policyholders with members located in multiple states.

Periodontal Disease and Insurance Billing

Posted on October 17, 2015 at 11:35 AM Comments comments (2339)

Perio and Insurance Billing Q: There are 10 things you need to know about getting paid for your perio services or services related to perio procedures.


A: Here are 10 FYIs with perio insurance billing: 1. New patients needing perio maintenance: need to find out when last quads were done. The quads need to be within last 2 years for perio maintenance to be covered by insurance. If you send it in without that information you might want to add another 60 days to getting paid for the claim.

2. Any gingivectomy or crown lengthening (especially done with a restorative procedure) needs perio charting prior to date of procedure and the charting should be attached with the submitted claim.

3. Many plan specific exclusion clauses will not pay for gingivectomies or crown lengthening with a restorative procedure on same date of service. Need to call and verify coverage when you are planning that clinical situation and might decide to split the procedures on two different days.

4. Many plan specific bundling of gingivectomies with crown procedures consider the perio procedure as part of the crown procedure. Again call to verify coverage and you might want to decide to do it on 2 different days.

5. All quadrant scaling (localized and full quadrant) you should submit perio charting at time of service to avoid insurance asking you for more information and delaying payment

6. Perio surgeries need perio charting, quadrant scaling date of service, and x-rays all submitted with the claim to avoid waiting time for payment

7. Many insurances you can not do all 4 quadrant scaling in one day

8. Frequency limitation: how often you can do quads need to verify coverage

9. Frequency limitation for perio maintenance: some insurances say you need to alternate prophy with perio maintenance, but the ADA states once a perio maintenance patient then always should be billed as perio maintenance.

10. Plan specific adjunctive procedures considered part of perio maintenance for example: Diode laser disinfection (its considered a tool used not a service)so patient pays in full.

What is the most ridiculous, confusing, most denied procedure dentists bill insurance for?

Posted on October 17, 2015 at 11:30 AM Comments comments (2992)

Q: What is the most ridiculous, confusing, most denied procedure dentists bill insurance for?

A: The simple core buildup has been redefined by both the insurance companies and the ADA in the past 2 years. Somehow, over the years, insurance companies have decided that the core build-up is part of a crown procedure and thus have avoided paying us for it. Delta Dental, Metlife, Guardian, Pomco all guilty of selling a plan to employers with the clause of core-crown bundling. How they got away with this bundling I have no idea. The fact is that not only do they not pay for it, but if you are a provider, by contract they don't let you charge the patient for it either! Another frequent denial is that “the x-rays reveal that THERE IS enough tooth structure present to support an indirect restoration without the core”! We have seen this denial with replacement of an existing crown. Now how on earth can the examiner see that there is enough tooth structure from an x-ray that shows existing crown blocking everything. Isn’t this crazy?.

Anyway, in response to this the ADA (in their 2014 dental codes update) came out with a new code D2949 (restorative foundation for an indirect restoration) to redefine clinically what we are doing. Now we need to identify whether we did D2949 (placement of restorative material to yield a more ideal form, including elimination of undercuts) or did D2950 (refers to building up of coronal structure when there is insufficient retention for a separate extra-coronal restorative procedure. A core buildup is not a liner to eliminate any undercut, box form, or concave irregularity in a preparation).

Let me tell you the implications here. First of all, often, the insurance companies do not cover new codes for at least 5 years. So if you are doing D2949 you need to charge the patient sicne there will not be any help from insurance there. By creating 2 codes our patients now have 50% chance of getting help from their insurance. The good old core buildup that was meant to improve the retention, to yield a more ideal form, to rebuild missing tooth structure, or to support the tooth after root canal procedure now is categorized pretty much by how much material you used and where. We all know that many cores are done to yield a more ideal form, including elimination of undercuts. Seriously? Why the difference, why did ADA do this to us? A core is a core…functions as a support to a crown no matter where or how much the dentin is rebuild or filled-in to eliminate undercuts. We get annoyed when submitting cores because often we get funky denials. There are way too many plan specific insurance clauses which in the end DO NOT pay for the core build-up. Especially in provider practices

HIPAA Compliance in a dental office

Posted on October 15, 2015 at 8:40 AM Comments comments (3457)

Rid Your Practice of Old Operating Systems (Windows XP and Server 2003):

Since April 2004, Windows XP has been left unpatched by Microsoft. You may notice on newer operating systems that updates are periodically installed when you restart or shut down - these come out every 2 weeks to patch security flaws that allow hackers to access your system remotely. If your office is even running one XP or Server 2003 computer, hackers have had almost 2 years to find holes in the system and those will never be patched (unless you are the US Navy and you pay Microsoft $30 million to extend it!). Even if the rest of your office is Windows 7-10, and Server 2008-2012, if hackers get access to one older computer, they are inside your network and the battle is lost.

Email Hosting, Email Encryption & Business Associates Agreement Best Practices:

While it is not mandated that your practice have email encryption if using a personally hosted email server, it is required if you use a public provider like Gmail, Yahoo, MSN/Hotmail, etc. Hackers can fairly easily get patient information that is sitting on the public providers’ servers. Also, using a public provider would only be HIPAA compliant if you signed a Business Associates Agreement (BAA) with Google, Yahoo or Microsoft. The problem is that none of these providers will not sign a BAA and take on the liability. Also, companies like Google automatically scan your email and generate ad traffic off your patients’ info, which is also a privacy violation. The best practice is to encrypt all emails – and better yet – it doesn’t break the bank at around $10-$15 per month.

Best Practices – Firewall Edition:

Using a firewall (i.e. Sonicwall) in between your modem and switch is mandatory for HIPAA. A proper firewall monitors all internet based activity in and out of the office. Even if you have a firewall, many offices fail to update their devices after the initial installation. Much like XP and Server

Dental Insurance "Lost" our Claim Again! They did not "receive" it?

Posted on October 8, 2015 at 6:55 PM Comments comments (6887)

Q: Why do dental insurances "lose" claims we mail them? What can be done?

A: We believe that it is the insurances tactic to delay payment. They hope noone calls to ask about the claim and with enough time it's too late for the claim to be paid on. Every insurance has a term that if the claim is submitted pass this time frame, for instance 6 months of date of service, the claim is an expired claim and they will deny it based on the time frame. Offices that have high unresolved claims lose a lot of money here because they can not keep up with the resubmission of corrected claims within this active time period. Here are 5 tips

1. Contract an e-claim service. This way you have a digital record of claim submission

2. Check claim status especially for high amount claims online. Most insurances have availibility to access claim status online this avoids time spent on the phone. Once you find out the claim status you can place calls on the claims that do not show up as received

3. Send claims certified. Believe it or not some insurances still do not accept electronic claims.

4. Have a contact person in each insurance company. Try to befriend the same person, get their extension so you can call direct. Very often they can push a claim through or you can fax over to them a claim that was not received.

5. Have a systematic insurance call day or days. Do not let things pile up outstanding unresolved claims need to be worked on regularly

Do you want to win or lose? What is the role of intra-oral photography in a dental practice?

Posted on October 8, 2015 at 6:50 PM Comments comments (20303)

Q: Do you want to win or lose? What is the role of intra-oral photography in a dental practice?

A: Here are the crucial reasons for intra-oral photography. If you are not taking pictures you lost the game. Below you will find a pdf presentation. Please save it on your computer or print it out and I want you to have a meeting with your hygienist within the next 2 days. Then enforce that your administration sends pictures and x-rays for all indirect restorations (along with the narrative described in the last post) with the claim at time of service (avoids waiting for the insurance to request this information).

Reasons for pictures:

1.Record of Health and/or Disease

2.Patient education tool

3.Visual communication of dental conditions

4. Support for narrative submission and billing

5. Baseline record and a way for comparison in the future

6. x-rays do not always show what you see clinically (the dental claims examiner reviews x-rays and does not see what you see).

7. Increases claim approval and expedites insurance payment

Hygiene Photography Downloadable Presentation from our website:

What narrative expedites dental insurance payment for indirect procedures?

Posted on October 8, 2015 at 6:45 PM Comments comments (3052)

Q: What narrative expedites dental insurance payment for indirect procedures?

A: There are 10 main indications (medical necessity) for indirect restoration placement:

1. vertical incomplete fracture of a cusp

2. complete fracture of a cusp

3. missing cusp

4. restoration is greater than 1/3 of the occlusal tooth isthmus

5. inadequate contact promotes periodontal disease

6 inability to achieve an adequate contact with direct restoration

7. new restoration will undermine cusps

8. abfracture lesion undermines a cusp

9. previous root canal

At diagnosis in hygiene or emergency exam, the Doctor has to provide a diagnosis which is one of the above and treatment plan a procedure to fix the problem. We recommend that the team drafts a document which includes those items to make it easy for the team to check off what the narrative for the procedure is, until it becomes second nature. On the day of service, this sheet can be pulled out and mailed to the insurance company with an x-ray and intra-oral picture (or the narrative can be typed right on the claim before its submitted electronically with an attachment of an x-ray and intra-oral picture) and you should see a payment in 3 weeks. By the way, if on the day of service you only send a claim without supporting documentation for indirect restorations, you can add another 6-8 weeks before this claim resolves. This is because first the insurance will receive the claim and has to process it (this takes up to 4 weeks), then you will send in documents (1 week), then insurance has to process these documents (2 weeks), then 2 weeks later they send a check.

Additional tip: when you are replacing an existing indirect restoration/and dentures you must ask how old that restorations is because usually there is a frequency clause in the dental plan and the restorations will not be covered within a specified period of time. Write the original placement date on the claim (don't wait for the insurance to ask!) For bridges, ask when the tooth was extracted that you are replacing and get in the habit of writing this information on the claim. Normally if the tooth was extracted prior to the patient having the dental insurance company you are billing, they will not cover the bridge.

What are the 3 top things that increase payment on claims within 3 weeks?

Posted on October 8, 2015 at 6:45 PM Comments comments (2716)

Q: What are the 3 top things that increase payment on claims within 3 weeks?

A: It's called sending a "clean claim".

1. Correct patient/practice/provider information (demographics).

40% of the time the front office forgets something

2. Submitting supporting documentation at initial claim submission

35% of the time the insurance delays payment by asking for more information

3. Correct insurance setup in patient account.

25% of the time the front office does not know how to setup the account especially in dual insurance, blended families, or plans that are administered by major dental insurances.

We recommend electronic claim service with attachment capabilities. One feature is that before claims submission the software will alert that there is missing information which gives the opportunity to correct it prior to submission. We have found offices that have e-claims service but are not using this feature?!?!? OR Have the service that does not allow supporting documentation availability (change the service!) Insider for Dentists: We as Dentists have no idea about the mistakes that are happening and the reasons for unresolved claims because the front office corrects them as they research the outstanding claims. We recommend Dentist meeting with their person responsible for AR from week to week and review claims status: 1) what was done from week to week 2) why the claim was unresolved 3) spot checking yourself. Call on some of the claims and see what's going on. You might see a trend. Set goals i.e.: "I want you to resolve at least 4 pages of claims by next week". Hope this helps!