Cracking the Code

As Seen in the Observer Magazine.

 

Dealing with dental insurance and all its limitations, restrictions, regulations, while trying to hit the constantly moving target, can be challenging at best, and impossible at worst.

Nevertheless, in many practices, dealing with dental insurance is a necessary evil that cannot be avoided.

There are some offices that are completely insurance-free, but that type of practice is a “unicorn” that, for most of us who work every day in the trenches of the dental practice, is not a realistic goal. Most of our patients with dental insurance expect the dental practice to deal with the headaches that come with submitting dental claims for those ever-diminishing reimbursements on their behalf.

Now that I have set the bleakest of images, is there any light at the end of the tunnel for those of us who deal with dental insurance every day of our work lives?

Yes, I believe there is.

The Need to Crack the Code

But to feel successful and fulfilled as an office manager, dental insurance coordinator, biller, coder, submitter, king, or queen of the dental insurance codes, the dental insurance “code” must be “cracked”. Cracking the code allows understanding, discernment, and unlocks the possibility of maximizing legitimate dental insurance reimbursement while reducing the regulatory risk that can be associated with submitting dental claims successfully.

You may be thinking, I know the dental codes.

Honestly, knowing the codes remains challenging even if they are used every day. If you know the codes beginning to end, congratulations. It takes years of study to know codes well enough to consistently select the best code that describes the service provided, as well as stay up-to-date on the annual code additions, deletions, and modifications.

Although insurance codes are daunting to learn and to remain current in, the more challenging aspect of dental insurance billing—the selection and application of the CDT code set—revolves around the administration of those codes.

How to Process Codes

By “administration,” I am referring to how the insurance industry, as well as the many varying plans, process those codes when selected and what can be done to maximize the legitimate reimbursement of those codes. Understanding the administration of dental codes will help provide accurate information to our patients.

Our patients expect accurate information from the dental team regarding their coverages. It is not enough for the dental team to understand coding and have access to accurate fee schedules providing information to our patients—it is also necessary to have “cracked the insurance code.”

The insurance coordinator must go above and beyond selecting the correct code to describe the service, affix the correct fee to the service, and take into consideration the multiple fee schedules that are developed in the dental insurance policy and administered by insurance companies.

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What Else is Involved in Cracking the Code?

Cracking the code requires a complete understanding of the restrictions, limitations and any unique “gotchas” embedded in the plan.

If the patient ever believes they were given incorrect information by the practice, their trust is diminished. Patient trust is one of the fundamental requirements for a successful, growing, thriving, positive and happy practice.

It is never a good day when the patient has completed treatment, paid their estimated co-payments and deductibles, and leaves believing they have paid what was owed…only to receive a statement 30 days later indicating the crown was not covered and they owe the practice the unpaid portion.

Trust is broken, and the happy, satisfied patient can easily become a vocal “enemy” of the practice—all because they were provided an incorrect estimate before the treatment was provided.

I know, I know, the patient was made aware that the figures provided to them were an ESTIMATE! In the real world, the patient seldom hears the word, “estimate”.

How to Crack the Insurance Code

So, how does one go about cracking the code?

Cracking the code requires a complete and thorough understanding of administration issues, such as:

  • Non-covered benefit legislation and how it affects what can be collected from the patient
  • Coordination of benefits
  • NPIs
  • In-network/out-of-network
  • Frequency limitations
  • The LEAT clause
  • Primary and secondary benefits
  • Documentation
  • Write-offs
  • Remapping
  • Inbundling
  • Credentialing

How in the world does an office manager, dental insurance coordinator, coder or treatment plan coordinator obtain an understanding of all the items listed above?

Seek to understand first and apply that understanding once it is obtained. Begin with one of the administrative challenges listed above and work through the list one by one until you have a good working knowledge of the challenge.

As part of the learning process, if you are surprised when an EOB comes, and it does not make sense to you, become a detective.

Anytime the EOB causes surprise, begin the process of uncovering the why. Was it an error in processing that will need correction? (Yes, insurance carriers do make mistakes processing claims.)

Familiarize yourself with the restriction and/ or limitation, unique situation or issue that caused the unexpected delay, denial, or request for more information from the carrier so you are not be surprised by the next EOB.

The more you know about the specific restrictions and/or limitations of each plan, the more accurate the “estimate” given the patient will be.

Become a lifelong learner by attending CE courses that deal with these issues to develop a better understanding of the administration of dental insurance plans, how they vary, and how to apply this information in your practice so that miscalculations are rare. Implementing corrections moving forward will ensure the specific issue is a thing of the past.

Cracking the dental insurance code requires a desire to do and be better and a willingness to learn and grow. These are personal traits that will benefit the patient, the team, and the practice.

Be a codebreaker and a smile-maker!

 

Are you ready to become the best dental office manager ever?

 

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