There are many moving parts when it comes to being an insurance-friendly practice.
Our patients know that we will do everything in our power to assist them in understanding and maximizing their dental benefits to help them achieve their best possible oral health.
Below are some guidelines so that our patients are completely confident that we are really here for them and have their best interests in mind.
1. Know Your Insurance Contract & Processing Manuals
This is not something I always knew; it’s something I learned about from podcasts and classes led by industry pros, like Teresa Duncan, MS with Odyssey Management and resources such as Dr. Charles Blair’s Coding With Confidence and Administration With Confidence books (which are updated annually).
For each insurance company that you’re contracted with, have a file with copies of your contracts, processing manuals, fee schedules (updated annually), and contact information for the designated provider relations representative for your area.
Processing manuals provide guidelines and exclusions that are often not found in the breakdown of benefits but will be in the Certificate of Insurance issued to the patient.
Also, keep a folder in your email or somewhere electronically documenting all emails regarding contracting, credentialing, and any correspondences with your provider relations representatives.
2. Documentation
Teresa Duncan said last year in her 2020 Coding Update Webinar, “Your documentation will drive your revenue.” Wiser words were never spoken.
Build a bulletproof case of evidence for all procedures. Not only does documentation protect you in the situation of an audit, but it saves time and money by avoiding unnecessary claim denials.
Let your doctors and assistants be the “detectives” compiling detailed evidence of dental/medical necessity through notes, and you will be the “attorney”, skillfully delivering this information to the insurance company “judges”.
There is no such thing as too much documentation.
Here are some of the different types of documentation to consider:
Imaging
If the necessity of the procedure is not radiographically evident, take intraoral photos as you diagnose.
If you’re submitting a photo of a cracked tooth that could be mistaken for a superficial craze line, consider using dye on the crack. Prep photos are also incredibly helpful in revealing the extent of fractures and decay.
Notes
Ding, ding, ding… Let me guess.
You come to your doctor with a denial. “Well, didn’t you send the X-ray?” they ask.
You: “Yes, of course, as well as all information available to me in clinical notes.”
Then, your doctor reveals that they removed the amalgam, and a mesial buccal fracture was present, undermining both cusps, requiring a full-coverage crown. It would have been helpful to have that level of description not only in notes but in imaging once the amalgam was removed.
Leave no stone unturned.
It’s helpful to have note templates that cover all of these bases and allow the provider/assistant to fill in the blanks. If you have good notes, you can screenshot them, and they will become your narratives for electronic attachments.
Here is an example of a clinical note template with information that should be included in notes for a crown:
Discussed the necessity of procedure with pt. and answered all questions? PA taken? Initial placement? Decay? Circumferential? Location? Condition and size of prior restoration (if applicable) Condition of remaining tooth structure Cracked tooth? How diagnosis was made? Tooth sleuth? Location of fractures and undermining cusp? Symptomatic? Endodontically treated? Caries, margins, broken porcelain, food impaction? Topical Anesthetic Preparation of tooth Surfaces Material Shade
3. Bill What You Do
That may seem like a no-brainer, but it’s a big one.
This is not only ethical, but it’s profitable and adds value to the services you provide from the patient’s viewpoint.
For example, the insurance companies that you’re contracted with may not allow you to bill your patient for local anesthesia, but you have every right to let them know that you used it and let your patient know that you write it off when it’s not covered by insurance.
This is a useful tool in keeping product inventory as well as maintaining proper records of the services you provide whether they are billable to the patient or not.
For instance, it’s important for us to document when we perform oral hygiene instruction, but this is a service we will never bill our patients for, even if it’s “billable.” You should always list on the claim form every service that is rendered for the patient with your office’s standard fees, so that their insurance company will have a history of these services.
If you write off something that isn’t covered for the patient but is billable, then that is totally up to you. Make sure your notes back up everything you do. Again, know your state regulations, contracts, and processing manual guidelines.
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4. Outsource What You Can
One thing you cannot outsource is outstanding customer service from a highly knowledgeable business team. This is priceless because a consistently positive customer experience is everything.
If your business team is understaffed, hiring a third-party company for eligibility and benefits verification may cost less than hiring a new staff member. Services also exist that will handle credentialing, outstanding claims, PPO fee negotiations, etc.
5. Have an In-House Membership Plan Available to Your Patients
Practices are embracing membership plans and dropping their PPOs left and right. Dental insurance companies throughout the years have created increasingly expensive and complex dental plans, that continue to turn a huge profit for them, but are very limiting to dentists and patients.
Membership plans are hugely beneficial for dental practices and their patients by removing the middleman and all the limitations and hassles that come along with them.
Dentists can provide their patients access to the excellent dental care they deserve at a discounted rate and still be profitable. It’s a win-win for both parties.
6. Stay Current
The world of dentistry is always advancing and changing, and with that, so is insurance and dental coding.
Continuing education and being up-to-date will allow you to have claims paid faster and with less error. Update your information annually.
There are endless resources through AADOM that can help you and your business team give your patients and dentists the peace of mind they deserve.
