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Keeping Your Patients Safe: Proper Dental Practice Infection Control Procedures

Proper infection control is a top priority of any dental practice to ensure the health of a patient is not compromised and to prevent the spread of disease and germs. Each dental practice must meet compliance and standards outlined by their state dental board. Achieving infection control is just the tip of the iceberg – it’s imperative to keep accurate and timely documentation of your dental office’s infection control policy and manual, staff training log, equipment and tool sterilization reports, etc.

Aside from maintaining the health of your patients and staff, having proper infection control protocol can safeguard your practice against retaliation. What kind of retaliation you may be asking? Disgruntled former employees. Time and time again, I’ve worked with clients who have experienced huge headaches because terminated employees alerted their respective state dental boards and made a claim on their former employer (insurance fraud, improper infection control procedures, etc.). State dental boards must investigate each claim they receive. Following a thorough weekly checklist of infection control activities can help keep your dental office up to date and ready for inspection at all times .

Infection Control Policies and Procedures Check List

  • Have a detailed infection control policy and manual for your dental practice printed and available for all staff members.
  • Keep a detailed training log that outlines each training, certification (i.e. CPR) staff member name and title, and their signatures confirming completion.
  • Keep a weekly log to record and stay consistent with sterilization testing of your dental equipment each week.
  • Some state dental boards provide an infection control manual. Obtain a copy online and use this manual as a guide to ensure compliance.
  • Plastic materials (i.e. x-ray holders) used to be the standard, but now tools must be autoclavable.
  • Never re-use disposable products. In attempt to save money, offices think they can wipe or spray these kinds of products for a second use.
  • Keep dental instruments in their sterilized bag up until they will be used on the patient. Reducing outside exposure will ensure proper infection control.
  • Always cover instruments, tools, and materials that may not be in use (i.e. containers for cotton balls). Aerosols can travel and stick to surfaces farther than expected.
  • Spend extra time wiping down every surface every time a patient is seen.
  • Keep your office’s ‘permissible practices document’ up to date. This document outlines all of responsibilities and tasks administered by each dental staff member.
  • Be sure to properly dispose of needles and biohazards, and keep documentation of removal.
  • Film x-rays are lined with lead – be sure to properly dispose of the lead foil. Additionally, save amalgam fillings for scrap metal.

Proper infection control management requires thorough documentation of your office’s day-to-day processes. Though infection control is expensive (I estimated it to cost $25/patient twenty years ago), it’s necessary for the health of patients, staff, and a well-run dental practice. Also remember, you don’t have to let the inspector in your office if they arrive unannounced. You can ask them to come back when the time is convenient for you.

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How to Leverage the Top 3 Underutilized Dental Practice Resources

One of the most common themes I encounter when evaluating a dental practice’s existing billing, scheduling, and management operations is the misconception that hiring additional staff or purchasing new technology is the go-to solution for solving areas that need improvement. When really the answer almost always lies in leveraging the resources you already have at your disposal to increase productivity, optimize schedules, and even grow monthly profit.

  1. Utilize the internet and insurance carrier web portals for eligibility checking.

Many insurance carriers have comprehensive online portals and websites available to check patients’ eligibility and obtain digital (PDF) reports that can be saved directly into a patient’s file. It’s common for front office staff to check eligibility over the phone, which is extremely time consuming and often very frustrating. Consistent negative feedback I hear from the front desk staff is the heavy workload due to the volume of insurance calls added to their other tasks. Using online portals and websites won’t fully replace calling insurance companies, but it will drastically reduce the time required and make this important task manageable. With less time being spent on eligibility checking, there will be less burnout and happier long-term employees.

  1. Maximize the existing employees your dental practice has on staff.

Dental offices often hire advanced qualified personnel (AQP) to help dentists provide care that a dental assistant or hygienist cannot. This hiring strategy when employed properly can allow the dentist to care for more patients.

I recently worked with a dental practice that had an AQP on staff, but was only being utilized at the skill level of a dental assistant. Instead of the dentist seeing 1.5 patients each hour (if the AQP was being utilized properly), the dentist was only seeing one patient an hour. The dentist was open four days a week and fully booked far in advance. Instead of needing to have an extra office day or extend hours, properly using the AQP to complete appointments would increase patient flow. Sometimes dentists are new to working with an AQP and have a tough time giving control over to someone else to finish his/her work. Since AQPs have a higher paygrade than dental assistants, it’s important to effectively schedule their time in harmony with the doctor.

  1. Learn every feature of your practice management software.

Staff Scheduling – Almost all software has a coding feature to easily visualize the staffing calendar to optimize appointment slots. For example, assigning colors to each personnel (doctor, AQP, dental assistant, etc.) can help the staff or office manager see the time requirement for each staff member against each appointment.

Appointment Setting – Utilizing the cancellation or broken appointment list feature can help in easier patient follow up and communication, and fill more open dental chairs when a cancellation occurs. For example, if a patient cancelled an appointment two weeks ago and it was recoded properly, and a last-minute opening occurs in the dentist’s schedule today, you can easily contact the patient to see if they can accommodate the opening. The patient will feel valued and top-of-mind, and the doctor can maximize his clinical time. Additionally, dental practices often invest in appointment confirmation services, like an email or SMS service. Instead of recording the responses from the service and then following up with patients to confirm via phone, I’ve seen front desk staff complete these tasks simultaneously, doubling up on their communication. If your practice pays for this type of service, fully utilize it – don’t pay for it twice (monthly subscription + staff hours)!

Treatment Plan Management – Many software systems can link treatment plans to an appointment for easier management and better results in the practice’s overhead. For example, a patient’s treatment plan could recommend work across three different appointments. One is scheduled the day-of the treatment plan review, but two are still open. As weeks or months pass by, you can run a report to show incomplete treatment plans, and allow for easier follow-up with patients. It’s important to always link a treatment plan to an appointment and add details (dollar amount, type of work, etc.) This will allow your practice to understand the projected monthly and annual income.

Prioritizing continuing education beyond your clinical staff is extremely important so your practice operations can run efficiently, saving time and money. Each client I work with always begins with reviewing overhead and finding areas that can be improved. Outsourcing time-consuming activities, like billing and eligibility, to experts can redirect practice staff time to focus on what matters most – excellent patient care. Dental Support Essentials offers ongoing support services including staff training, practice management services, credentialing, billing, and eligibility.

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Strategies for Forecasting Revenue

Twelve months, 52 weeks, 365 days. A calendar year offers endless opportunities to deliver excellent personalized dental care to individuals, families, and communities. As we all know, life happens, schedules change, vacations and holiday breaks occur, and dental care may not be top of mind for patients. There are two months – September and February – that traditionally experience a dip in appointment volume. Patients are going back to school in the fall and winter weather can keep patients from making their appointments. A dip in appointment volume can affect your practice’s average monthly production, but don’t fear – there are smart strategies you can implement to prepare for these traditional slow performing months so you have a level average monthly income.

Increase Appointment Availability During High Volume Months

In comparison, the most popular months for dental services are August (pre-back to school), December (holiday break), and January (the time to maximize dental benefits and HSA/FSAs). The best strategy I’ve implemented and have seen succeed across practices to offset the slow months is to increase appointment availability during the high-volume months. It may seem a bit counter intuitive to increase an already high patient influx, but the key is to maximize these popular times for the patient.

Offering additional hours or opening your practice on a Saturday will show your patients you care and will build goodwill. Showing patients, you are considering their needs and schedules, and offering them a thoughtful solution will set your dental practice apart. You are a part of the patient’s community – a trusted healthcare giver that plays a vital role, likely over different life stages and years.

Practical tactics you can implement to aid your dental practice see more patients during these busy months are:

  • Use a dental staffing agency to hire one or two extra temporary hygienists. This will allow you to see more patients during your normal office hours. Make sure to plan and book extra staffing at least six months in advance of the winter holidays.
  • Extend your office hours – an hour or two earlier or later than usual – to accommodate patient’s schedules.
  • Consider opening your practice on a Saturday for half of the day. Patients will appreciate the weekend availability, since the work week may be difficult to schedule around other commitments.
  • Specifically target school-aged families through direct mail (i.e. post cards) or emailers to inform them of your extra appointment offerings. Look up the holiday schedule of the local schools online to help advise which days you should market.
  • Try to book teeth cleaning appointments in early August or December, so there is enough time to schedule any additional work later in the month.
  • Increase promotion of custom fit mouth guards during the month of August for the school year’s sports. All athletes – football, basketball, baseball, softball, hockey, wrestling etc. benefit from well-fitted mouth guards. It’s smart to offer these at an affordable price, since patients could opt for a cheaper, not as well-made mouth guard from general sporting goods stores.

Maximizing your practice’s busiest months will ultimately bring your patients increased satisfaction and goodwill. In addition to happier patients, your annual production forecast will be more accurate, since you adjusted to cover the slower months. It’s also very important to not spend the increased money your practice made during these high-volume months. This cash flow is to cover the slow months, it’s not the time to buy new equipment or remodel the front office. A bit of planning, extra staffing, and marketing can go a long way in making a meaningful impact with your patients and your practice have an accurate and dependable annual income.

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Dental Provider Credentialing 101: Medicaid Management

Over the past few weeks, I’ve detailed the ins-and-outs of the dental provider credentialing process – a painstaking, time intensive, detailed, and necessary procedure for the modern 21st century dentist to stay competitive and offer dental care to an expanded in-demand patient base.

There is a niche subset of dental care that requires even more scrutiny and exhaustive efforts to complete credentialing. Medicaid, which is managed by each individual state, requires additional manpower, maintenance, and vigilance for effective dental credentialing. Because of the momentous effort required behind providing Medicaid dental care, it’s recommended for clinics with larger infrastructures and not the solo practitioner. You must work twice as hard to get paid half as much than the traditional in-network or out-of-network dental patients.

Medicaid Dental Provider Credentialing

  • Medicaid credentialing requires a double application process – first complete the traditional dental credentialing application with the state, then get credentialed with one or more Managed Care providers (i.e. DentaQuest, United Concordia, etc.).
  • Medicaid can be different in every state, so you’ll be registering with the individual Medicaid state program.
  • You’ll need an individual Medicaid provider number, as well as a provider number for your practice.
  • Remember to plan accordingly, as the Medicaid credentialing application always takes longer than prescribed. Many states say they will approve applications within 90 days, which often doesn’t happen and delays the payment process and affects the practice’s bottom line.

Medicaid provider companies are notoriously understaffed, which results in slower processing time. These companies have also increased automation and electronic processing. When it works, it works well, but if there is a problem, it’s a nightmare to fix since it’s more difficult to get a person on the line to help.

A Medicaid Dental Case Study: The Devil Is in The Details

As mentioned several times throughout this dental credentialing series, closely managing the details is imperative to the financial health of your practice. I recently helped a dentist, who provided Medicaid services, dig out of financial distress and suspected fraud, all due to a single application error.

This dentist was seeing patients using four different Medicaid carriers and PPO plans, and quickly realized her pay was significantly lower than it should be based on her high volume of patients. My first instinct was there may be a claims submission issue, so I resubmitted the claims, but each got denied because they were previously paid. But there was one big problem with this finding – no checks were received by the doctor. After a few calls and emails, I discovered these checks were being mailed to an address that didn’t exist. How could this happen? Someone manually entered the wrong address number on the credentialing application. One simple initial error had a disaster domino effect and negative impact on an entire dental practice and quality of life of a dentist.

Medicaid is a unique system, and since there is no central governing body, each state and provider is different. In this case, the missing checks caused me grave concern because we didn’t know if they were being cashed, which raised a huge red flag of potential fraud. With the risk of fraud present, I escalated this case immediately to Medicaid provider executives, yet it was received with no sense of urgency. It took me months to correct this error after several meetings and dead ends. Because of this one error and ensuing arduous process, the dentist was unable to make money and ultimately ended up leaving Medicaid dentistry.

The biggest takeaways about Medicaid dentistry and credentialing is the amount of manpower and vigilance that is required to see success. It takes dedicated resources and time to manage these minute details, carefully record the status of each application, and diligently communicate with the credentialing companies. Carefully evaluate your existing internal resources and patient demand to understand if you have the necessary manpower available to manage a Medicaid practice.

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Dental Provider Credentialing 101: Common Application Mistakes to Avoid

As discussed in part one and two of my dental providing credentialing blog series, it’s important to fully understand the implications of providing in-network vs. out-of-network care, allow ample time for the application process and take a detailed, thorough approach with the insurance companies during the inquiry process to negotiate the best fees schedules.

Now that you have a strong foundational knowledge base of the dental provider credentialing process, it’s time to address common application mistakes, so your credentialing can be completed in a timely manner and patients can be seen sooner.

  1. Be sure to complete each application response, even if the question doesn’t apply to your practice (i.e. enter in N/A). If a response is left blank, the insurance companies often consider it an incomplete application.
  2. Ensure your malpractice insurance is current and up to date during the credentialing approval process. The approval process can often take up to 90 days, so contact your malpractice insurance provider and extend the policy if it is set to expire during this timeframe.
  3. Always include detailed supporting documentation that outlines the changes in the practice (full details below).
  4. Plan and allow ample time (~3-6 months) for the approval of your dental credentialing. Credentialing is not a quick process, which is often the biggest headache experienced by dentists, since approval can deeply affect which patients can be seen (in-network vs. out-of-network).
    • Ensure all forms (W-9 and attestation page) and signatures are up to date and as recent to the application submission date as possible. The application process could be delayed if your forms are too out of date (i.e. you might start getting credentialed with the big companies first, and wait 3-6 months until targeting and applying for the smaller ones. Even though the forms have been completed and collected already, since considerable time has passed, you need to make sure the dates are near the new submission date.)

The Importance of Supporting Documentation for the Dental Credentialing Application

Providing detailed supporting documentation is instrumental to the timely approval of a dental credentialing application. Specifically, a detailed letter on the dental practice’s letterhead should clearly articulate the details of the changes. I find it best to display this information in a table format with big, bold headings. Details to include in the supporting documentation are:

  • New doctor’s name, tax ID and license numbers.
  • What doctor(s) are staying at the existing practice, leaving the practice, their identifiers, and the effective date the change will take place.
  • If you’re changing locations or working at multiple locations, be sure to clearly detail and label the locations. You don’t want your new credentialing to cancel out your old credentialing, which can happen due to confusion on behalf of the insurance company. This is as simple as providing the new doctor’s tax ID number and adding it to the old practice as a new location.

Dental Credentialing Management Tips

Implementing a sound credentialing management and tracking process will help your practice stay on top of communications and status updates with the insurance companies.

  • Confirm the application was received by the insurance company. Follow up in a consistent, friendly manner until you have confirmation from the insurance representatives. Outreach over email is best so you have a written record of communications.
  • Follow up with the insurance companies on a weekly basis.
  • Keep a detailed spreadsheet that records the status of each application including, insurance company name, contact information, call log, and detailed notes.
  • Utilize an online calendar app to keep track of reminders for follow up calls, emails, etc.
  • Be professionally obnoxious and stay diligent in follow up, until you’ve received a response and confirmation of your credentialing application. If you do not receive a response, it often means they did not receive it!

Working with several practices over the years, I understand how painful the credentialing process can be with insurance companies. It’s a timely, detailed process that requires nonstop management and diligent follow up. Though the credentialing process is a bottleneck in dental practice management, it’s a necessary process for practices and doctors because so many people rely on their dental insurance to afford the dental care they need.

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Dental Provider Credentialing 101: Application Process & Insurance Inquiries

Last week, I gave a full rundown of dental provider credentialing basics and outlined initial steps to get you started and make a confident decision to provide in-network or out-of-network patient care.

There are often two categories aligned with the dental credentialing process when establishing or joining a dental practice – (1) you may already be an in-network provider from a previous dental office or (2) you’re beginning the process from scratch. If you’re already an in-network provider, find out who you’re in-network with and the process is simple – it’s a matter of updating your practice’s address and new tax ID number, usually by completing an update form specific to each provider.

If you’re starting from scratch with the dental credentialing process, completion of a full application is necessary. Several states have a universal dental credentialing application using CAQH ProView, which requires an in-depth look at several documents. A full list of documents and identifiers for submission include:

  • National Provider Identification (NPI) number – An NPI number can be applied for online and is cost-free.
  • Dental license for the state you practice in.
  • Proof of malpractice insurance – Submit the page of the policy that outlines the length of time and amount of coverage you have.
  • DEA certificate – This is received from the federal government to prescribe medication. It’s important to password protect this document.
  • Certificate or diploma for a specialized degree – If you’re a specialist (i.e. orthodontics) you will need to provide proof of completing the specialization.
  • Additional board certifications (i.e. pediatric board certified).
  • W-9 form – This documentation reports your income to the federal government and could be different per dental practice you are employed by. You might need more than one W-9; it needs to belong to whoever is receiving the check.
  • Professional references – The CAQH application requires professional references (i.e. colleagues), but often are not actually contacted for application approval.

The best place to start and guide your application is your professional resume and personal information records (SSN, date of birth, etc.). Once you’ve completed and submitted your application, you’re ready to start reaching out to the dental insurance companies and begin making inquiries.

A RoadMap for Dental Credentialing Inquiries with Insurance Companies

  1. Visit the insurance company’s website. There is a section specifically for providers (i.e. ‘join our network’), which is where you’ll submit the initial credentialing inquiry.
    • Helpful tip: It’s smart to create a generical email address just for credentialing to help manage the credentialing process and documentation management.
  2. After the initial inquiry, the insurance company will send you a contract to review and sign (but often with no fee schedule).
  3. Ask the insurance company for their fees schedule, as well as their electronic funds transfer paper work to begin the process of account setup (you’ll need a voided check).
  4. After reviewing the insurance fees schedule, it’s time to negotiate. Insurance companies never offer their best rates up front, but will usually negotiate up to 20 codes. If you’re a specialist or live an underserved area, you will often have more leverage to negotiate.
  5. Pay attention to your most commonly billed codes (i.e. exam, filling, including amalgam, crown codes, and denture codes) and negotiate higher fees for these more highly used codes. Insurance companies will go back in forth no more than 2-3 times to settle on a fees schedule.
  6. Be sure to review and negotiate downgrade clause codes. Dental insurance companies often have fee loopholes around downgrade coverage. For example, a white filling is performed on a patient and the insurance has 80% coverage for white fillings, but the said fee policy has a downgrade clause attached (which can be buried in documentation), and the insurance company pays 80% coverage for only silver fillings. The patient will not receive the expected coverage due to this downgrade clause.
  7. Always set up direct contracts with companies that negotiate. If you do set up a direct contract, always make sure to opt out of the third-party fee schedule, so the insurance company uses the higher fees schedule (which is typically lower when a third-party firm is involved).
  8. Consider working with a third-party credentialing firm to assist with fee negotiation and management. Third-party firms can often help negotiate higher fees, but will likely only contract the work if you agree to an added paid service (i.e. using their claim service, etc.)

One of the top reasons I’ve seen for frustration and burnout among dentists is the exhaustive amount of time that can be required for credentialing and fees schedule setup and management. Dentists often reach a point to make the decision to join a corporate dental practice or engage outside dental practice management expertise if they want to maintain their sole practice. What has your experience been with dental provider credentialing?

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Dental Provider Credentialing 101: Part I

As dentists start their career and establish, join, or take over a dental practice, there is always an elephant in the room that needs to be addressed and decided upon: to be credentialed or not to be credentialed?

To answer that question, let’s define the basics of dental credentialing – what it is, why dentists decide to get credentialed, and the initial steps on how to begin the dental credentialing process.

What is Dental Provider Credentialing?

Dental credentialing is the process of a dentist entering into a contract with an insurance carrier. The doctor then becomes a provider of that insurance carrier and gains access to a larger patient base, therefore increased business opportunities. Insurance carriers have a very thorough, in-depth vetting process for dentists to become credentialed including providing proof of dental degree and dental license, malpractice insurance, law compliance, Americans with Disabilities Act compatibility, etc.

The Dental Insurance Carrier Contract

It’s important to thoroughly and carefully read through the insurance carrier contract ahead of signing it. The contract outlines the plan the dentist is participating in, fee schedules, and what the dentist can and cannot charge the patient. It’s common for dentists to sign the contract document without fully understanding all of the contractual obligations. For example, signing the contract often gives the dental insurance carrier permission to audit the dental practice and documentation. Additionally, insurance carriers can determine if certain procedures are billable or not. Often, insurance companies will not allow dentists to bill the patient for a procedure (i.e. crown buildup) that would normally be billed if the dentist was out-of-network.

In-Network vs. Out-of-Network

The majority of dentists today belong to at least one insurance carrier network. More and more patients rely on their dental insurance for affordable dental care and are co-pay sensitive. Often the question “what does my insurance pay?”, is the driver for completed appointments and treatment plans. Alternatively, dentists can choose to work outside of insurance networks (out-of-network) resulting in more direct payments and less insurance management, but there is a good chance the patient pool will be significantly smaller. Out-of-network patients will generally pay higher out-of-pocket rates and fees.

Dental credentialing is also on an individual basis, so if multiple doctors reside under one practice, each can choose to decide if they want to be in-network or out-of-network and what plans they accept. Each dentist will have to be credentialed individually with each insurance provider. One application cannot be completed for the whole practice if multiple dentists wanted to fall under the same insurance carrier.

Where to Start with Dental Credentialing

  1. Research and understand the top large employers in your city and county (i.e. hospital and school systems) and which insurance carriers they employ. Joining the insurance carrier that local major businesses use will put your dental practice among a large in demand customer base.
  1. Review the insurance carrier fee schedules. Sometimes these fee schedules don’t have a fair payout (i.e. Medicaid fee schedules) and end up costing the dental practice more. You have to ask yourself if it’s worth being a part of said network. Don’t sign or turn in a contract without reviewing a fee schedule. Many times, I’ve had to ask more than once to review the fees.
  1. Understand your competition and what the demand is for different insurance carriers. The front office staff can start by making a list of the insurance plan patients ask to participate in and calling around to other local dental practices. Choosing what insurance carrier to join can be tedious, so you’ll want to be selective and negotiate fees.
  1. If you’re buying a dental practice, you’ll likely choose the insurance carriers that the former dentist participated in to include existing patients. It’s important to talk to the front desk staff for intel on existing plans to determine any changes or adjustments.
  1. Are you already a credentialed dentist? If you have been working in a dental practice prior to buying or starting a new practice, you may need to only to fill out an update form for the insurance company. As stated before, the contracts are with the individual providers so your contract (not necessarily the fee schedule) can be linked to more than one location. Find out from the office manager of your current practice which companies you are currently participating with and contact them to get provider update information.

Itching to know more about the ins-and-outs of dental provider credentialing? Over the next few weeks, I’ll continue to break down the details and nuances of dental credentialing and provide tips and tricks, so each dentist can make a confident decision.

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Common Dental Insurance Pitfalls — Part 2

Post-Appointment Dental Insurance Claim Management Checklist

The patient’s dental appointment wraps up, they’ve received a comprehensive detailed treatment plan with all insurance implications identified, and the patient has made a confident and informed decision to proceed with the recommended dental work. It’s all smooth sailing from there, right? Not quite — the dental insurance and dental claim management processes have only just begun with the completion of the treatment plan.

Last week, I detailed common dental insurance pitfalls that can occur during pre-appointment front and back office activities, including not investigating deeper with the insurance company beyond the preliminary report to develop a comprehensive, fully detailed treatment plan, not giving the front office staff enough time to develop the plan for the patient, and not differentiating multiple plans under a single dental insurance carrier.

To ensure compliance and coverage with the dental insurance carriers post-appointment, it is critical to have a tight methodical management process in ensuring every little detail is covered for the dental claim to be approved.

Post-Appointment Insurance Claim Checklist

  • Provide thorough, detailed evidence of clinical documentation of the work that needs to be performed (i.e. x-ray v. intraoral photo documentation, detailed notes, and description of the problem, etc.)
  • Send the correct x-ray needed to document the problem. Explain to the insurance carrier exactly why the work needs to be done. The more you spell it out, the easier it will be for the insurance carrier to understand the problem and approve the claim. Details to include are the tenure of the dental problem, history, and type of recommended treatment (replacing a crown v. repairing the old one).
  • Double-check to make sure the claim actually made it to the insurance company. If the payer ID or ID numbers are incorrect on the claim, the claim won’t make it to the insurance company. Call the insurance company and clarify what ID numbers are needed (payer ID from the insurance card or social security number) to ensure claim delivery.
  • Provide a list of insurance payer ID numbers at the front desk for easy cataloging and submitting of claims.
  • Check the ‘rejections’ file in in your dental claims software. Claims that need additional proof can be rejected and be filed away automatically, which can be missed if not regularly checked and cause a delay in payment.
  • Differentiate between the (1) rendering provider and (2) billing provider.
  • Pay close attention to the input of patient information (payer ID, ID numbers, etc.) into the insurance software management system. Providing adequate software training upfront will help mitigate mistakes and increase the likelihood of claim approvals and ultimately getting paid.

Most Common Treatment Denials: Periodontal & Cosmetic Work

Common treatments that see the most dental insurance claim denials are periodontal and front teeth work. It’s difficult to prove the patient actually has the disease, but differentiating between the prevention and active treatment of the gum disease is imperative for payment approval. Provide a strong narrative that describes the presence of the disease and provide additional pictures beyond the x-ray, like intraoral cameras.

Insurance carriers often categorize anterior restorations as cosmetic, which isn’t covered by most insurance plans. The best approach is to always tell the patient that front teeth work could be denied and provide the full price before they start the treatment. Having the conversation upfront will allow for no financial surprises after the work is complete.

Dental claim management is an important priority in day-to-day operations of a dental practice. Having a dedicated expert to manage this process is an efficient option to maximize collections and overall workflow among the back and front dental office staff. A claim expert understands the different nuances of each insurance carrier and can detect patterns for more efficient and collected payments.

What common post-appointment insurance pitfalls beyond this list has your dental office experienced recently?

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Common Dental Insurance Pitfalls — Part 1

Insurance helps the public access health and dental services at a more affordable cost. It’s a necessary component to the healthcare industry and economy. The work required for effective dental insurance management and processing requires strong tact in thorough investigation and research practices. Without these strong practices in place, it’s easy for a dental office to fall victim to common insurance pitfalls that can negatively impact operations, collections, and patient retention.

Working with different dental practices over the years has uncovered common insurance errors experienced among the front office and clinical teams. Common dental insurance pitfalls to avoid include:

  • Not investigating beyond the initial information the insurance company volunteers in the insurance coverage report;
  • Not giving the front desk staff enough time to complete a thorough treatment plan; and
  • Not differentiating multiple plans under a single insurance carrier.

Smart Investigation with Insurance Companies

During the initial dental treatment planning process, it’s common for insurance companies to return a report with preliminary information, but not necessarily include full in-depth details like waiting period and replacement period limitations, treatments received, and benefits used (in the current coverage calendar year). Investigating beyond the preliminary information received is integral to fully understand the treatment coverage and payment implications.

I recently saw the mistake of staff not investigating deeper beyond the information volunteered by an insurance company. A patient’s benefits were checked against their insurance and the practice was informed they had benefits for restorative work (50 percent covered). The doctor’s office then performed the prescribed restorative work (a crown) and submitted the claim, which was denied due to the patient not being covered for a crown. During the appeal process with the insurance company, I was informed the insurance company doesn’t consider crowns restorative, even though the ADA code book states crowns are restorative. This particular company considered crowns in their “major services” category and the patient did not have coverage for “major services”. Ultimately, the patient ended up having to pay 100 percent of the procedure because someone misread the breakdown of benefits. According to this patient’s plan, a crown was a major procedure, and nowhere on the benefits breakdown did it say no coverage for “major services”, it just showed what they did have coverage for. The dental office staff can’t assume insurance companies are going to disclose all necessary information upfront in the initial check. Yes, this may seem backward, but it’s the process at play and must be played correctly for the benefit of the patient and financial health of the dental practice.

Develop a Well-Researched Treatment Plan & Timely Patient Communication

We’ve all heard the saying ‘time is money’. This is particularly important when informing patients in a timely manner of their dental treatment plan. When the patient is in the chair, clinical reasoning is fresh in their mind, but once the pain has subsided, they leave the office, go back to their life and forget about making a timely treatment decision. The urgency of the treatment has subsided and patients often think an intermediate fix is sufficient enough if they are not fully informed on further care and treatment options.

The back and front office need to work in harmony during the patient’s visit to produce an accurate, well-informed treatment plan. This starts with the clinical team giving the treatment coordinator enough time to put the treatment plan together before the patient is sitting across from her. The coordinator should be explaining the financial options and scheduling the appointment, not still researching the details of the plan. Among the financial implications, the treatment plan should explain to the patient the cause, effect, treatment option(s), and what could happen if the problem isn’t fixed beyond the doctor’s assessment. This gives the patient a choice and responsibility of making an informed decision in a timely manner.

Providing accurate insurance and payment information to patients before a procedure (beyond preventative care) is the lynchpin to satisfied and trusted patient relationships. Slowing down, taking an investigative approach, and asking detailed questions with the dental insurance companies will help your dental practice avoid these common insurance pitfalls and rise above towards dental insurance management excellence.

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Fall In Love With Your Accounts Receivables Process

Managing the accounts receivable department can often become a thorn in a dentist’s side. Beyond the patient care, it’s the accounting details, process, and management that can have a deep, lasting impact on a practice’s day-to-day operations and overall success. It’s important for dentists to be confident in their business and have a strong understanding of their cash flow and payment processing. A strong system of checks and balances that defines a clear roadmap for all staff can lead to more successful management and accurate accounts receivable activities.


Set Up Electronic Funds Transfer

A surefire process to set up accounts receivable success is to set up electronic funds transfer accounts with the dental insurance carriers your practice does the most business with. Insurance companies will pay the practice directly and create a report of deposits. This report can then be matched and reconciled with the internal accounts receivable report from the front office staff and be reported to the bank. Electronic funds transfer accounts may change the way you have to reconcile banking, but ultimately it helps increase accountability for business reporting and operations.


Check Insurance Before Seeing the Patient

Checking insurance eligibility and details ahead of the patient’s appointment is an integral step to understanding payment types and the practice’s collections. Payments typically fall into two categories (1) over-the-counter, or same day payments and (2) plan-based payments over a period of time. Labeling payment types will allow for a quicker assessment of the practice’s collections and understanding of an up-to-date and accurate accounts receivable status.


Create and Implement a Practice-Wide Financial Policy

Taking time to create and define a concrete financial policy for your practice will instill confidence in each team member across the business and be a strong guide for financial-based conversations with patients. Offering different payment options (ex. in-house payments per visit or financing) will help meet each patient where they are financially. The financial policy outlines clear rules, but it is ultimately up to the dentist to ensure consistency of its use, so the financial health of the practice can be well.


Review Monthly Production, Collections and Outstanding Receivables Reports

To understand the financial health of the practice, create and review reports each month on the practices’ production, collections, and outstanding receivables numbers (which starts with accurately labeling each payment type). These reports will help give answers to important questions including:

  • How much was collected on the date of service?
  • How much was collected from Insurance?
  • How much was paid as a result of a statement being sent out?


Having a clear understanding of each month’s payment flow can help inform better strategies for increased collections.


Outsource Billing

In years past it was common for front office staff to have a longer tenure with a practice. Today, the positions tend to be more entry-level and be inhabited by staff who learn the skills and want something more, causing higher turnover. Front office turnover can cause lapses in billing processes and activity. More practices are turning to billing consultants and experts to handle their accounts receivable and ensure a concrete process no matter the changes that may happen among the practice’s front desk. Outsourcing helps increase accountability, consistency, and give the doctor confidence that their finances are being managed by one source and won’t be influenced or dependent on staff changes.


Managing your practice’s accounts receivable process doesn’t have to cause headaches and uncertainty. Sound processes, documentation, and automation can all contribute to the financial wellness and success of a dental practice.