Check out your local “help wanted” listings…. most employers are looking for someone with 1 or more years of “experience” in the position they are looking to fill. Over the last 35 years of my career in clinical, administrative and academic dentistry, I have discovered that “experience” is over-rated. This is exceptionally true with the admin team. Let me explain.
In a practice, once the patient has had their diagnostics & treatment consultation, they will be turned over to the person that handles the insurance and the financial arrangements.
This is where all of your hard work and credibility can implode without proper training. Coding and billing is the one position that has the most financial impact on your practice, and that impact can be profitable or catastrophic.
A well-trained insurance administrator is a very valuable team member. They can usually assist the Dr. increase monthly production by several hundred to several thousand dollars, but It isn’t good enough to have experience, you must be an expert…. EXPERIENCE IS NOT EXPERTISE
Have you invested in formal training for your “insurance administrator “? Who actually trained that person? Was she trained by the “girl that did the job before”? Or is she doing things a certain way because that’s “how I did it in my old office?”
I have had administrators tell me that “the Dr. doesn’t care, so why should I?” That way of thinking can put your practice at risk, clinically and legally, in the form of insurance fraud.
As dental professionals we should set our personal bar very high, always making sure our number one priority to exceed the standard of care.
That being said, the responsibility for proper coding starts with the clinical team. I say that because the documentation from the clinicians MUST be accurate if the insurance administrator is going to be able to code properly.
Here are a few examples of things I see:
A patient has a 3-unit bridge, but only because the abutments are prepped, that’s what gets documented, so that’s what gets charged out, so the pontic revenue is lost.
Tooth needed extracted and added to existing partial… many times that could have been the tooth that was clasped, so not only do we need a new tooth, we need a new clasp. Lost revenue because clasp not billed out.
BW & 2 pa taken on a hygiene patient… after exam Dr. needs one more pa. BW get billed out but only 2 pas… more lost revenue.
I have had office managers say,” well that’s only 1 pa”. Yes, but let’s say 1 pa @ $25.00 x 3 times a day x 4 day a week x 4 week a month = $1200.00. Would the manager feel differently if “only “those PA’s were gone from her check? They are certainly gone from the Dr.’s! These things all factor in when the team is asking for raises, or more benefits.
Fraud most often reveals itself in situations such as:
When a practice will perform a perio maintenance yet bill out a prophy. They do this because it “helps” the patient to be compliant because they have no co-pay.
A patient may be losing their insurance on the last day of the month, but can’t get in until the first. Again, in order to “help” the patient, services are dated prior to the end of the month. After all, it is only a day or two, right?
Charging out for an acrylic partial when a stayplate was fabricated.
Billing a full gold crown when a noble crown was delivered.
I could go on & on & on, but you get the idea. When doctors find themselves in trouble, there is no intent to commit fraud or supervised neglect. Nevertheless, the Doctor is responsible.
If the ENTIRE team is not properly trained in accurate, exact, documentation and coding, it will result in a loss of revenue, & could even be considered insurance fraud. Insurance fraud is definitely not a road you want to take. Fraud can lead to fines, disciplinary action, license probation or revocation, and possible incarceration. Insurance fraud does not have to be intentional to be prosecuted and auxiliaries are not exempt.
Let’s look at this example:
#6-11 pre – auth was sent for Pontic Porcelain to High Noble & Abutment High Noble. The plan re-assigned the codes & approved for Pontic Porcelain to Base Metal & Abut Porcelain to Base Metal.
When the pre auth came back, NO ONE noticed that the codes were re-assigned to a lesser benefit OR that even though it was “approved” the patient was well over his max. No one advised the patient what his financial responsibility would be.
Treatment done…No consent form, no financial arrangements. No communication regarding treatment plan change in the chair to an all ceramic bridge. Pre auth was sent for payment, the insurance paid and the patient was billed the balance of several thousand dollars. Would you want to be the one that answered the phone when the patient called? The patient filed a grievance with his insurance company and the Dental Board. The Dr. was held responsible. The insurance company performed an audit and the Dr. was ordered to re-imburse the insurance company, and the patient would owe $0. I’m sure the patient loves their free bridge!!
Team training would have avoided this & brought the approximately $11 thousand dollars of revenue to the practice instead of back to the insurance company and patient. In reality, the loss is much higher. The Dr. had to absorb chairtime, wages, lab fees, & materials, but perhaps the biggest cost was damage to the reputation of the practice.
Regardless of how much a patient loves a dentist, they will turn in an instant if the financials are not what they expect. And you better believe that everyone they know on Facebook will hear about it!
By investing in team training on coding and business systems, you can actually get paid for the procedures performed, reduce stress, and your patients will be happier.
