Navigate Medical Billing

Sep 18, 2013 1 Comment by

Medical billing in a dental office? How is this possible? For the past 17 years, I have experienced, firsthand, successful reimbursement from medical insurance in a dental setting. You may be asking, “What could medical insurance cover for a dentist?” Well, I am here to answer that and give you the 5 most common challenges that will help you conquer medical billing, like your own GPS!

1) Understand your Audience (a.k.a. insurance)
Like everything in life, it is better to understand as much as you can about what you are trying to do. Medical insurance will only consider reimbursement if treatment is medically necessary. Establishing medical necessity is essential and must be done in writing. Think of it like billing a crown: we may accompany the claim with a narrative and/or x-ray to show that the crown is needed. Medical insurance needs to know why your patient needs your treatment. Pain, accidents, infection and dysfunction can prove to be medically necessary which, ironically, form the acronym PAID! Exams, x-rays, sleep apnea oral appliances, TMJ orthotics, bone grafts, oral surgery and implants have all been reimbursed by medical insurance when the treatment is medically necessary. Medical insurance typically does not reimburse for tooth-related dentistry (i.e. fillings, crowns, bridges or root canals) except in the case of an accident to natural teeth. Have you ever come across a medical insurance that says, “We don’t pay dentists?” If so, you are not alone. If you get this response from the medical insurance representative you are talking with, make sure you let them know you have established medical necessity and need to confirm benefits.

75% of medical claims that are denied to dentists are reimbursed after one appeal.

2) Prepare Proper Documentation

If there is one thing I have learned when dealing with medical insurance companies it is to never say never! Each insurance company works differently. Yes, there are similarities in how they process claims; however, each policy will have its own rules and regulations. It is very important that you research the medical policy for specific documentation needed. A CMS 1500 medical claim form is needed to submit. Most medical insurance companies will not accept a dental claim.

As we learned above, a letter of medical necessity should accompany a medical claim from a dental office to establish the need for the treatment. This information should be submitted in SOAP format:

• Subjective- patient’s symptoms and dysfunctions
• Objective- clinical notes and records
• Assessment- clinical diagnosis with ICD medical diagnostic code(s)
• Plan- patient’s suggested treatment plan with CPT medical procedure code(s)

Researching medical insurance can be done over the phone or online. One thing that is very important when researching is to find out if the treatment you are planning requires prior authorization. This is the process of sending the insurance an explanation in writing before treatment is completed and, if approved, the insurance will send you back a confirmation code to proceed with treatment. In some cases preauthorization is required for the insurance to contribute.

3) Invest in an electronic system
Many medical insurance companies do not process handwritten claims. When a handwritten claim is submitted it is not scanned into their system like an electronic claim; it must be processed manually (which can slow the process down extensively.) Preparing SOAP reports for each patient and understanding how to communicate the medical necessity in medical terminology can be time-consuming. Initial documentation to support what you are billing is extremely important. The insurance may not request documentation every time you submit, however the documentation will support the medical necessity and is essential to the process.

I have had the pleasure of working with Rose Nierman of Nierman Practice Management and DentalWriter™ software for over 10 years. She created DentalWriter™ specifically for dentists billing medical insurance. This software provides an easy way to gather patient-specific symptoms, dysfunctions, and diagnosis along with clinical information to automatically generate reports of medical necessity and electronic medical claim forms.

Attempting to bill medical insurance with handwritten claims and dictating narrative reports of medical necessity for each patient can become tedious and daunting. Investing in a system can pay off. Depending on what you are billing, your investment could be recouped after just a handful of claims. Imagine running your dental office without your dental software. It can be done, but it will be very difficult when it does not have to be.

4) Know your subject
75% of medical claims that are denied to dentists are reimbursed after one appeal. Remember that if a treatment is medically necessary and a claim is denied, you can appeal. If the insurance simply denied the claim because it was submitted by a dentist, they may be looking for confirmation of medical necessity. This is why continuing education is a must! The more you are educated on the subject the better your chances are for proper submission. The diagnostic ICD and procedure CPT codes are constantly changing, along with rules and regulations. It is vital that you keep up with the changes! In January of 2011, Medicare approved reimbursement to a dentist for oral appliances for sleep apnea. Two things are important here:

• Medicare approval means private insurance follows Medicare’s lead.
• The device is provided and billed for by a licensed dentist DDS or DMD.

This decision reinforced the fact that dentists have a place in medical insurance reimbursement. If oral devices for diagnosed obstructive sleep apnea are something you are considering for your patients, now is a great time to get educated on the subject and bill medical insurance for it.

5) Follow up
Like dental insurance, it is imperative that claims are tracked and followed up on. Insurance companies can make mistakes and if something is not right, check it out! Always remember that, as with any insurance the policy, the contract is between the patient and their insurance. Your assistance in billing insurance should be a courtesy extended to your patients. Medical billing and the documentation you provide will aid in your patient’s payment of services to you and help your patients get needed treatment!

Insights, Summer 2013

About the author

Glennine Varga is a certified T.M.D. assistant and educator with an A.A. of sciences. She is a certified T.M.D. assistant with the American Academy of Craniofacial Pain. She has been employed in dental education for over seventeen years. Glennine is certified in radiology, electrodiagnostics, expanded duties dental assist, and in the treatment of temporomandibubular disorders, she has been a T.M.D./Sleep Apnea trainer with emphasis on medical billing and documentation for over ten years, and has been training the use of electrodiagnostic equipment for five years.

One Response to “Navigate Medical Billing”

  1. Heather Richardson EFDA says:

    Great Article! Love this subject! Especially when it benefits our patients! What a great addition to the dental field! It is definitely hard to implement in a busy dental practice. I am in the process of learning this myself between patients 🙂 Thank you for the encouragement! It will be worth it for our office and my doctor! These are medical issues and should be treated just as that!

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