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This page is intended for personnel in the dental industry.  Please be respectful in your comments.  

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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

What is the number one reason for patient's dissatisfaction with their dental office?

Posted on October 8, 2015 at 6:55 PM Comments comments (3951)

Q: What is the number one reason for patient's dissatisfaction with their dental office?

A: Billing/financial issues. When we start our training with our clients, the first thing we teach is how to correctly put together financial agreements with patients. This includes a lot of scripted verbiage to communicate with patients our expectations, what we anticipate insurance will do for the patient (often what insurance will NOT DO for the patient, LOL), and make sure that information is secured in a signed agreement between both parties. Few key pearls we can give you

1. We DO NOT estimate insurance, but rather we tell the patient that "We would like to collect $____to start the procedure. We will send a claim to the insurance and when the claim resolves we will resolve the balance that could be a balance due or a credit." The amount we collect at time of service is close to what we expect insurance to pay, but we do not tell the patient that because they hold us to it and as we know insurance plays their own game and is unpredictable even with a pre-determination.

2. We encourage 3 or 5% pre-payment at time of diagnosis for their next visit and schedule them. This commits a patient to the appointment and prevents no shows. (It also increases your cash flow)

3. We put a "?" in the field that says remaining balance due because we want to reiterate that we really do not know what the insurance is going to do. Then we are not locked into predicting what the insurance will pay exactly.

4. We do not send pre-determinations. This step is a waiting game and prevents booking the schedule. We all know that pre-determinations are NOT a guarantee of payments! It says it right on the pre-determination form.

5. We prepare the FA (financial agreement) for ALL procedures without exceptions, even for insurance companies that pay 100%. That's because if they don't eat it! Because, the patient will tell you that they would have not proceeded if they knew they would have to pay out of pocket, etc.

Here is a sample financial agreement from our website.

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 (3053)

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!

What is a healthy/managable amount of insurance and patient balance in over 30 days?

Posted on October 8, 2015 at 6:35 PM Comments comments (2608)

Q: What is a healthy/managable amount of insurance and patient balance in over 30 days?

A: The industry shows that there should be no more than $3000 to $5000 in total over 30 days aging unresolved insurance/patient balances per $80,000 of production for one Dentist operation. This is an indicator of how effective is the office in their financial policies and working the accounts receivable.