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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.

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What To Know Before You Purchase Dental Insurance

Insurance is convoluted, to say the least. Throughout my years of being a dental office manager, I regularly get calls from a patient who are looking over re-enrollment forms. They were un-acquainted about this process it seems as the forms were written in a extraneous language for them. They also have questions about the whole process like how do I know what type of coverage I need? What does endodontic mean? Do I need coverage for that? etc. I had always said that I wish I could hold a seminar for my patients before they bought insurance. So here are my guidelines for informed purchasing of dental insurance. It is my belief that you should approach the purchase of insurance with knowledge of the following items:

  1. Your dental health
  2. The clauses and limitations of the plan
  3. The insurance company’s reputation for customer service.

Dental Health

A person’s dental health can be impacted by overall body health, personal habits, and consumption. Conditions such as diabetes, medication-induced dry mouth, as well as, habits like smoking, poor diet choices, and, refusing to floss also increases the occurrences of gum disease and tooth decay. It can damage the teeth. Many patients don’t understand that grinding is not just an annoying habit; it can leads to fractures, gum recession, and broken fillings. If you have any of the previously described problems, you may want to consider a more comprehensive plan.

Clauses and limitations of the plan

The day you have a toothache and leave to see the dentist is normally a bad day to find out you have a six month waiting period on all treatment except cleanings. When looking at a plan ask the following questions:

  • Is there any waiting period for any category of treatment?
  • Do alternative benefit clauses or exclusions apply?
  • What is the yearly maximum?

Some plans only cover a limited amount if procedures for an initial waiting period. That me ans in the first months of your plan they will only pay for cleanings, and if you need any other category of care you will have to cover the cost Some plans have alternative benefits clauses. Most commonly we see this clause regarding fillings. This provision states that while your dentist may have performed a composite filling on your tooth the insurance will only cover the cost of silver filling, and you will have to pay the difference. The same applies to many tooth replacement procedures, and your dentist may have placed a fixed bridge or an implant but your insurance will only pay for a removable partial denture, and you will need to cover the remaining cost. It’s important to know if your plan has an alternative benefit section before the work is done. Your plan benefit sheet may say you pay 20% on fillings. After the downgrade, clause is applied your cost is closer to 40%. You also need to consider exclusions. Some plans just do not allow composite fillings, bridges, or implants and will not pay even an alternative benefit. They will only deny the claim and the entire cost will be yours. When limitations like this are written in the plan, they typically do not get paid on appeal. Also, watch for age limits on procedures. Many times fluoride and sealants will only be covered on certain teeth of patients who are in a complete age range. The age range is different for each plan. Most plans have a yearly maximum. Commonly it is $1000.00. This means after they have paid $1000.00 in insurance claims they will not pay any further claims for the benefit year. That includes services that are naturally covered at 100% such as cleanings. So if you exceed your benefit for the year and have not had the second cleaning of the year, it will be an out of pocket cost. These are not the only restrictions that can be unnoticed in a dental plan but they are the most common things we have to explain to our patients in the dental office. Knowing these aspects of your plan can prevent painful financial moments during your time of dental need.

Customer Service Reputation

The name of some insurance carriers cause your dental staff to cringe when they see you pull out that card. We know that we will not get clear or complete answers when we check your benefits, and so we will probably be on the phone for 25 minutes repeating your name, birth date and ID number a minimum of 5 fives as we are transferred from person to person. We can’t get a good breakdown of benefits; therefore we can’t be perfect on quoting your costs. We don’t like to shock patients with extra costs. We don’t want to have that conversation any more than you do. There are various insurance companies that provide the information quickly, completely and accurately. The carriers that have the best online service typically are also easy to deal with on the phone. So consider this. If I have 20 years ‘of experience dealing with dental insurance and I cannot get the answers I need from your plan, how well will they assist you if you need to call? I was once in a discussion with a patient considering two plans that were very comparable and my answer to the patient when they called me was, “Both plans pretty much function the same but XYZ company has better customer service in my experience.” Insurance is not getting less complex. Patients have more plans available to them and it can be hard sometimes to know what options to choose. It’s important to know what your plan does or does not cover before you pay the premium only to end up paying again at the dentist.

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Front Desk Staff: The Lifeline of a Dental Practice

From appointment setting to a warm in-office welcome, front desk staff has the opportunity to make a lasting impression (positive or negative) with patients before a patient even lands in the dentist chair. As the first and last interaction with patients, and a multitude of duties in between, those who manage the front desk and internal operations are the lifeline of a dental practice — the business simply wouldn’t be able to function without these necessary and important team members.

As we all know, front desk staff members have an abundance of daily tasks to manage and juggle beyond the patient-centered responsibilities, which are the top priority. With the influx and changing demands of the day-to-day workflow, the presence of thorough processes and knowledge sharing will heavily influence the success of a dental practice. Throughout my career, I’ve worked in many dental practices big and small, starting as a receptionist and working my way up to practice management. Understanding the dental practice industry from all angles has given me a unique perspective to implement a variety of change activities to improve efficiency, management, and workflow. No matter what the opportunity is for improvement, I’ve found it always links to front desk staff. I’ve seen what works and what doesn’t. Below, I offer concrete strategies to avoid the top common mistakes often experienced by front office staff. Addressing these common pain points and implementing structured processes will have your dental practice operations running smoothly in no time.

Common Front Office Mistakes Experienced in a Dental Office & How To Avoid Them

  1. Dental practices often invest in business management software to help operations and workflow but bypass proper training. Without proper training, staff can create extra work for themselves, since the software process and usability can become a guessing game. Investing upfront in appropriate training will build confidence in your staff and ultimately create efficiencies and more time to focus on what matters most.
  2. Sometimes the front desk staff can have the perception that the dental practice has a very high cash flow. They may see that thousands of dollars are being collected and believe that the practice is healthy, but not understand how many thousands of dollars it takes to fully run the practice. This may cause a lack in sense of urgency in collecting insurance payments and misrepresent the practice’s actual bottom line. Establishing a strong collections process and continually reinforcing the importance and impact collections have on the business’s success will properly educate staff and help them understand how their roles contribute to the organization.
  3. Informing each patient of their estimated out-of-pocket (OOP) costs for procedures — ahead of the work — is fundamental for more satisfied patients and collected payments. This may be one of the most important tasks for the front desk staff. This process occurs in two steps: (1) verifying the insurance and documenting the insurance coverage before the appointment and diagnosis and (2) explaining the coverage and OOP costs after the diagnosis and before the treatment is performed. Patients don’t often fully understand the differences between their medical and dental plans, so clear and accurate information sharing is key for patients to make confident decisions.
  4. Lastly, I’ve seen that front desk staff can have a fear of talking about money and procedure costs with patients. If the treatment plan is extensive, difficult conversations may need to be had. But what’s important, is that each patient deserves a custom approach and transparent conversation so they can be empowered to make informed decision. Hiring employees who are confident communicators about money, finances, and payments will help build stronger, more transparent relationships with patients.

Establishing well thought-out processes and procedures for practice operations are foundational to creating happier patients, a more confident dentist, and a well-respected valued dental team. An additional successful approach that takes the billing and operations pressure off of the front desk staff and practice, is investing in a practice management consultant. Deep knowledge and expertise from an independent outside resource won’t impact daily operations and will allow the entire staff to focus on what matters most, delivering quality and compassionate care to patients.