Insurance can be frustrating for any practice, but these tips can put you and your patients at ease.
When Dr. Charles Blair first started out as a dentist, he says you could run a practice the way you wanted to. Profits were higher back then and dental school debt was lower (if it existed at all). Even reimbursements were better.
Now, the margins are tighter, the PPO fee is 30 to 40 percent off the dental fee, and dentists today are graduating with student loan debt that tops $100,000. All of these things, Dr. Blair says, come into play when dealing with dental benefits in the practice.
We spoke with dentists and dental benefits experts to find out what solutions are best for easing the stress of dental insurance. Here is their advice.
Continue to the next page to see the top tips.
1. Include solid documentation
“What I have found to be most helpful is documentation,” says Erinne Kennedy, DMD, a dentist at a community health center in Boston. “The insurance company is looking for specific criteria in your documentation, so if you are able to give them exactly the information they need with the correct verbiage, reimbursement is easier. Accurate and detailed documentation, including radiographs or intraoral pictures, reduces an opportunity for the insurance company to deny the claim.”
Patti DiGangi, author of “DentalCodeology,” calls documentation one part of the “two Ds” - documentation and diagnosis. “What’s the diagnosis, and what’s in your documentation to support that diagnosis?” she says. “That’s called a dental medical necessity. We don’t think that way in dentistry yet, but we need to because there’s not a medical claim that’s paid anywhere that doesn’t have a documented medical necessity.”
She believes that documentation and coding is a team sport that can’t be left to one person. “The clinical professionals have to provide the information and the data that needs to go on claim forms,” she says. “The one thing we’re missing most often in dental offices is diagnosis. We’re not currently required to use diagnosis codes, so all we think of is procedures. The biggest question I get is about how to code things, but they don’t know the diagnosis, they just know the treatment.”
If you’re not sure of the criteria that insurance companies require for documentation, Dr. Kennedy advises calling the insurance company to ask.
“Personally, I keep a little list in the office of the insurance company’s criteria,” she says. “When I send in a pre-treatment estimate or claim, I know that I am sending the exact documentation needed for that procedure.”
2. Understand coding
“The problem that I see in offices is that they don’t understand coding,” DiGangi says. “They don’t know the difference between coding, fees and coverage, and those are separate but related entities.”
“Every company has 30, 40 or 50 different policies that they offer,” says David Rice, DDS. “Knowing which procedure codes a given policy works with and which ones they don’t, and which ones you can bundle together as opposed to which ones you can’t, is really important. With some policies, you can come in and get an exam and I can take X-rays, but I’m not allowed to take other types of X-rays with it. But if you literally came back tomorrow, I could take those X-rays and they would be covered. So, having a coding expert is really important.”
“They should have a copy of the current code set,” says Teresa Duncan, dental insurance educator and host of the “Nobody Told Me That!” podcast, which focuses on managing issues in the dental office. “A lot of people depend on the practice management software having the codes, but it often doesn’t have the full code descriptor. They need a book that has the full description of the code in it, so they can make sure their doctors are doing exactly what is in the code and that it matches the best. We’re supposed to do the procedure and then see if there’s a code that accurately describes it, not find a code and then only do what’s in that procedure code description.”
3. Use the PPO manual
“Where there’s a disconnect of information is on insurance administration,” Dr. Blair says. “We’re up to the point where there are about 14 PPO plans per each indemnity plan.”
Dr. Blair says that the lack of knowledge that practices have in the PPO arena is “troubling.”
“For instance, everybody knows that there is a contract with the PPO, but nobody knows that the contract says you are supposed to adhere to the processing policy manual. That manual might be 150 pages. It really spells out the relationship between the practice and the PPO.”
The manual outlines several aspects of reimbursements that many practices may not be aware of such as how to handle optional services, the need to report all charges, the option to reject or disallow procedures, and how to handle “dual” insurance.
For handling optional services, Blair gives this example: “If I were doing a very complex case - a $25,000 or $30,000 case - and my crown fees are $1,000, I can’t level arches and do provisionals and everything for $700, which is the PPO fee,” Dr. Blair says. “So, I get an exclusion. That’s one thing in that processing policy manual.”
Blair also stresses the need to report all charges, which he says includes tooth whitening. “They are supposed to be sent to the PPO for review,” he says, “even though they’re not going to pay for certain procedures. For instance, they would not pay for tooth whitening, but they might control the fee. We call that fee capping for non-covered procedures.”
Plans can also deny or disallow procedures. “Deny means they’re not going to pay it, but you can collect from the patient,” Dr. Blair says. Disallowing a procedure “means the insurance won’t pay and you’re prohibited from charging the patient.”
He argues that a lot of offices leave money on the table between denied and disallowed procedures.
Dual insurance comes up about 15 percent of the time, Dr. Blair says, and many practices don’t realize that the benefits are coordinated and that the practice can collect up to its full fee.
If the dentist treats a dependent who is under both his or her mother’s and father’s insurance plans, the doctor can be reimbursed through a coordination of benefits. “The doctor could be in two low-fee PPO plans and actually get their full fee,” Dr. Blair says. “That means that we get two checks. A lot of offices don’t realize that - they want to give money back because they think they’ve been overpaid. But if I put $1,000 on the claim form, then I can keep up to $1,000. I have not been overpaid unless I get above the fee that I place on the claim form.”
4. Consider outsourcing
“Outsourcing is definitely where offices are realizing a lot of efficiencies, so they may want to investigate those options,” Duncan says. “What I mean by outsourcing is to farm out benefits and eligibility checks and also answering of the phones. So many services are doing it very well that it’s not unheard of anymore.”
She advocates outsourcing for cleaning up outstanding claims as well.
5. Support organized dentistry
“In Massachusetts, there has been a lot of conversation around certain insurance companies in our state,” she says. “I think supporting organized dentistry (either local, state or national components) as a profession is an important way to make sure that dentists and patients are being represented in the legislation.”
“There is no other large voice out there,” she adds. “Insurance companies have lobbyists. The ADA and AGD are there for the same purpose. When people want to effect change but are not part of a large organization, it’s a harder task. When you have a large body advocating on your behalf, your concerns will get more attention, as opposed to trying to knock down doors on your own.”
6. Have a knowledgeable insurance coordinator
Dr. Blair says that it takes more and more sophistication to run the front desk, so having a well-equipped team there to handle the business side of the dental practice is essential.
“I have a receptionist in my office who knows all of the insurance companies, their pricing and their coverage, down to some of the individual plans in my state,” Dr. Kennedy says. “I think that alleviates a lot of communication issues with the patient if you can say, ‘I’m going to connect you with so-and-so. She knows your insurance inside and out and if there is something she doesn’t know, she’ll help you find it.’ Having that person makes it easier on the patient and the doctor and ensures that when you submit all of the information to the insurance company, you’re reimbursed in a timely manner.”
Unfortunately, many practices don’t have an official insurance coordinator. Instead, they lump in the duties of an insurance coordinator with the rest of the duties that the front desk manages.
“There are very few people who take any kind of training because there is limited training,” DiGangi says. “They learn what they think they know about dental benefits from articles, speakers, the internet and social media, and all of those contain misinformation.”
Because the CDT codes are owned by the ADA, one must be licensed to write or speak about them in an educational capacity. DiGangi is licensed.
“People say all kinds of things from the podium, but it’s not necessarily accurate because nobody polices it,” she says. “There’s a lot of missing information from which we create our treatment plans, which is unethical. A treatment plan shouldn’t be based on coverage. And if someone creates or doesn’t code accurately or changes the code just to increase insurance payments, that could be fraud. Whether it’s by accident or ignorance, it’s still fraud.”
She says that, in order to make the process better, there needs to be a better understanding of how it works now.
“We need to understand the system versus fighting the system,” she says. “We spend more time fighting and complaining instead of getting involved in it and trying to understand it so that it can be fixed - because it needs to be fixed.”
7. Identify your patients’ benefits and eligibility ahead of time
Duncan asserts that checking patients’ benefits and eligibility ahead of time is essential, though not that common.
“It sounds intuitive, but I still run into a lot of offices where they don’t do it because of time,” she says. “They should focus on identifying benefits and eligibility for at least their new patients. Then, focus on those who have big procedures upcoming so that we are confident in our co-payment estimates. If your practice management software automatically checks it or you have it done through an outside service, then you don’t have to worry about the time issue. You’d be able to open your software and have it be right there.”
She also advises logging in to the insurance company websites regularly to check benefits.
“The biggest issue I run into is that people don’t know patient benefits and don’t even bother checking on eligibility,” she says. “And they also don’t do it often or consistently enough. That leads to lower confidence in the information given to the patient. That’s where the breakdown happens between the patient and the office. Patients are never happy to receive an unexpected bill.”
Duncan says that knowing patients’ benefits ahead of time raises the level of customer service in the practice.
“Hospitals make you sign a million forms to acknowledge that you’ve been given a cost estimate,” she says. “In dentistry, we don’t do that consistently. That leaves your office and the patient open to all sorts of confusion.”
8. Commit to yearly courses and stay updated
The rules are complicated and they change often. That’s why Duncan believes that the insurance coordinator should take a refresher course every year on the new codes.
“At least once a year, take a webinar on the new codes,” she says. “Lots of people provide that. I give a webinar every January that goes over what’s coming up for the next year and any noticeable trends.”
She also advises keeping up on the trends outside of your own practice.
“When they go to study clubs or society meetings, they’re finding out what’s going on in other offices, which is super helpful,” she says.
“A good insurance coordinator today is not someone who’s just entering checks and filing claims all day. It’s such a changing market. They really need to be proactive about staying on top of it. If a doctor hears from their insurance coordinator that they don’t need any classes or if they notice that the person hasn’t taken any classes in the last two or three years, the landscape has already moved on. That person may be working inefficiently.”
Many of the sources interviewed for this piece are experts in the arena, with lots of resources available: Sign up for Teresa Duncan’s newsletter or podcast, “Nobody Told Me That!”, check out DentalCodeology by Patti DiGangi, or visit Dr. Blair’s website, which includes books like “Coding with Confidence, the ‘Go To’ Dental Coding Guide.”