The Dental Billing Podcast

A HIPAA-Centric Approach to Dental Billing

• Ericka Aguilar • Season 11 • Episode 1

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Uncover the critical connections between HIPAA compliance and dental billing practices in our episode featuring host Ericka Aguilar. Discover how safeguarding patient privacy extends beyond ethical boundaries to play a pivotal role in averting billing fraud in dental practices. We delve into the cutting-edge strategies employed by insurance companies, such as predictive analytics, to detect inconsistencies and initiate audits without relying on whistleblowers. Erika sheds light on the risks associated with common pitfalls like inappropriate code adjustments and the negligent waiving of co-payments that insurers might interpret as fraudulent activity. By gaining a deeper understanding of insurance audits and adhering strictly to HIPAA's privacy, breach, and anti-kickback policies, dental professionals can uphold their practice's integrity and maintain the trust of insurance companies.

Explore the heightened scrutiny dental offices face due to the rise of AI in insurance auditing, as Ericka highlights the dire consequences of billing inaccuracies, including high denial rates and the ominous threat of clawbacks. With the potential for significant financial repercussions, she emphasizes the importance of accurate billing and the dangers of fraudulent resubmissions. Learn how diligent denial tracking and effective appeals can be your defense against unnecessary audits and penalties. Hear practical advice on how to navigate the complexities of maintaining compliance, including when to involve the insurance commissioner to protect your practice from potential pitfalls and maintain ethical billing standards.

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Perio performance formula:

(D4341+D4342+D4346+D4355+D4910)/(D4341+D4342+D4346+D4355+D4910+D1110)


Want to know what your fee should be for D4346? Send Ericka an email to ericka@dentalbillingdoneright.com


Speaker 1:

Hi there, welcome back to another episode of the Dental Billing Podcast. I'm your host, erika Aguilar, and in today's episode we are going to talk about a HIPAA-centric approach to dental billing. I meet with a lot of offices all over the country and while we are talking about billing, the focus is on billing and accuracy and all of the coding things and staying up to date. And now the conversation has turned towards diagnosis codes and we're going to get into that in another episode. I want to talk about what is lacking in most billing departments, which is understanding that HIPAA and billing go hand in hand. And if you think that your office is not being watched, think again. Insurance companies do not need a whistleblower to put your office under scrutiny. They use predictive analytics, sophisticated data tracking systems that flag high-risk practices behind the scenes, and by the time you find out, it's probably too late because they've already built a case up. A lot of the audits that are conducted are flagged by some of the billing practices that I see every day. One of the biggest things that I see violations that I see would be maybe the patient came in for perio maintenance and the perio maintenance was denied because the patient only has the benefit of a prophy. Sometimes insurance companies will just pay for the benefit of the prophy, but there are times when it'll indicate that the patient is not eligible for perio maintenance and then we'll change the procedure code to what the patient is eligible for, and that is going to be monitored. What you are resubmitting, the level of resubmissions, the level of denials, can trigger these audits. And we want to make sure that if and when because, let's be honest, there's no office that is going to be free and clear from going through any type of audit at any point during that practice lifetime If and when this happens, we want to make sure that we have our I's dotted and our T's crossed, because we don't want to get to the point where so much of it has happened that now we find ourselves having to defend the practice billing process to the insurance company or, even worse, to a judge.

Speaker 1:

So there are some things that I want to talk about that you need to be aware of as a dental biller, so that you're not unintentionally violating HIPAA but also committing fraud, because sometimes violating HIPAA means committing fraud. First, let's understand the purpose of an insurance audit. The purpose of an insurance audit is so that the insurance company can assess accuracy, compliance and integrity of the claims that you're submitting. They're also going to assess the use of coding and billing guidelines and billing practices. They're also going to assess whether or not there's fraud happening, whether it's intentional or not. Ignorance is no excuse to the law. So you have to know whether or not you are committing fraud, and so being compliant with HIPAA is going to help you avoid those mistakes. Over billing, they are going to look specifically for waiving of co-payments, because that is considered fraud, especially if you are in network. Actually, if you are taking insurance money from the insurance company, it is considered fraud when you waive a copayment and you do not inform the insurance company. So be very careful with that. I see a lot of this happening with new patient specials. When we're bundling services together and then we have a patient that comes in with PPO insurance, we need to let the insurance company know that we gave the patient a discount on the x-rays or whatever you did in that new patient visit and it was bundled for a new patient special. If you are billing insurance, you've got to be very careful with that, and that's a whole other episode that we can dive into at another time.

Speaker 1:

Finally, they're looking for accountability in the dental industry. So they're just holding offices accountable to payment processing guidelines, to all of the laws. The benefits to a dental insurance audit is going to ensure compliance in your office and it's going to mitigate fraud right, because they're looking for it. They're looking for upcoding or unbundling of services so that you're not benefiting financially, so that you're not benefiting financially, using the codes in the way they are intended to be used, not in a way that benefits you financially. I know that sounds harsh, because I do want you to get paid for what you do, but I want you to get paid compliantly. I don't want workarounds in my billing departments because workarounds can commit you to fraud and I don't want that. It's going to maintain your relationships with your insurance companies and hopefully it's going to be an educational tool that is used so that you learn from the things that you were found to be doing, from the things that you were found to be doing incorrectly, right? So we want to make sure that we are on the up and up.

Speaker 1:

Now, what exactly is HIPAA and how does it have that direct correlation to billing? Can you tell me and this is a rhetorical question, obviously, because I cannot talk to you directly. Can you tell me what HIPAA stands for? You're a biller or a practice owner? Can you tell me what HIPAA actually stands for you send me an email. Hipaa is regulated and enforced by a subdivision of human health services called the Office of Civil Rights. If you were to report a violation of HIPAA, you would report it to the Office of Civil Rights and some of the provisions and policies that fall under HIPAA the HITECH Act of 2009, and you've probably heard about that by now. If you haven't, we'll talk about it in another episode. We've got quite a few follow-up episodes coming down the pike here, so just bear with me.

Speaker 1:

Privacy policy we need to follow. Breach policies. We need to follow protected health information policies and anti-kickback statutes the anti-kickback statute, which again which again I see that one violated a lot with new patient referral and these packages that are put together it's really important that, as we are promoting our office, we're not violating any of those policies. So how do we violate HIPAA as billers? Well, the first way is, if you are a biller and you have a third-party billing company, you need to have, or you are an office using a third-party billing company, you need to have a signed BSA business service agreement and this is going to be your get out of jail card in the event one of the two parties violates HIPAA. This is going to keep your business secure and safe. So make sure that you have that completed and fully executed before you start working with any third party. And this doesn't only apply to billing companies, friends. This applies to all third party vendors that are going to have access to PHI. So you want to make sure that your third party vendors have signed a BSA, or also known as a BAA.

Speaker 1:

We also violate HIPAA as billers if we are sending x-rays without a HIPAA-required encryption emailing system. So if you're using, like, a free Gmail account for your office, you're probably not using a HIPAA encryption standard of email account, so you want to make sure that you're doing that. And waiving copayments and not informing the insurance company is a form of a HIPAA violation, because it's violating the anti-kickback statute. So we want to be very careful with all the things that we're doing. But we want to be mindful, we want to be accurate, we want to code for what we do. We want to make sure that we're not violating any of these policies the privacy policy, the breach policy. We want to make sure we have BSA signed and we also.

Speaker 1:

This is a biggie, and I know this is a biggie because in 2023, we did a survey and we called about 100 offices and we asked when was the last time you had a HIPAA training for your entire team? I would say 90% of the offices had not heard about this, had not done it or hadn't done it for quite a few years. It is a requirement that you have a documented annual HIPAA training for the entire team in the event you violate HIPAA. Because in the event you violate any of the policies or you get accused of violating, the first thing that you're going to be asked to present by the Office of Civil Rights, they're going to ask you for the last six years of the HIPAA required documents. They're going to want to see your privacy documents. They're going to want to see your privacy policy. They're going to want to see everything. But one of the other things that they're going to want to see is proof of the annual HIPAA compliance training, and if you cannot provide proof of any of these things that training is a biggie you may end up owing in fines, and these fines can start at $1,500 and go all the way to hundreds of thousands of dollars. So you want to be very careful with that, because when or if one of your vendors breaches and you don't have a signed BSA, you are guilty of the breach as well.

Speaker 1:

So I want to make sure that we understand, as billers, that our billing practices are being scrutinized on the back end. They are utilizing the power of AI to put together stats on our office. They're looking at our fees, they're looking at how many denials we get. Denials can trigger your office to be flagged as a high risk office, and I've seen offices that have had to submit everything 100% of the time for a pre-authorization because it's such a high risk office, and when that happens, you are also running the risk of losing participation of that network. So we want to make sure that there's low denials. You can't eliminate denials from a practice because denials are not always based on clinical merit, and I've talked about this in other episodes. Sometimes denials are based on budget and sometimes denials are based on the fact that insurance companies are utilizing improper denial tactics in order to control budget. That does happen. But also we can also receive legit denials because we're just not billing properly.

Speaker 1:

And when that happens, the insurance company is taking notes and they're looking at resubmissions. They're looking specifically at the resubmissions, at whether or not the same date of service or the same patient if that procedure code was changed. Now I'm not saying that that doesn't happen legitimately. Sometimes we cross-reference different patient files and it happens. Right, it's a one-off. But when the insurance company is red flagging that because there are too many resubmissions, then they're going to scrutinize that and they're going to look at that and think, hmm, I wonder why this code? They submitted this code, we denied it and now they're resubmitting with a different code. That is not a claim correction, friends. That's a resubmission with the intention of changing up the code to benefit financially, which is fraud. So you have to be very careful with this stuff because they are monitoring. There have also been instances where the insurance company has reported the practice or the doctor of record on that claim to the dental board. Now these are extreme examples, but it does happen and I want you to be aware of it because now, with the power of AI and all of this predictive analytics that the insurance companies are using, they can virtually predict which offices are going to end up as high risk offices and then they'll determine how they're going to manage that.

Speaker 1:

This can also include fines. Not only will you owe money back to the insurance company, you could also lose your participation status, which, in my opinion, in today's billing era, I don't think that's a bad thing. But that's again. I digress All right. So what is a clawback and how is a clawback triggered?

Speaker 1:

So, first of all, a clawback is when an insurance company demands repayment for a claim it previously paid. It's a good old refund request, also referred to as a clawback, and this is going to happen when the insurance reviews the claim and decides it should not have been paid. A lot of times they will determine or find a coordination of benefits error, and maybe they find that they should have been secondary but they paid as primary, and now they want their money back. Another way that insurance companies can trigger audits is when we have a ton of patients reporting billing errors or billing issues or issues related to copayments. When that happens, that is going to trigger a review and we've got to make sure that we've got our ducks in a row, because we want to make sure that we've got our ducks in a row, because we want to make sure that we're not overcharging the patient for things that they shouldn't have paid for, and that's going to issue an audit that can lead to a clawback. And clawbacks are a big issue, right, because insurance companies can demand refunds years after paying them. You may have already paid the lab and the overhead costs for that procedure and now you have to give the money back. That's not fun. If clawbacks keep happening, it's a signal to the insurance company of poor billing accuracy and insurance companies are going to flag you for an audit.

Speaker 1:

Keep a log of your insurance denials. I know we do that for all of our offices. We have a denial spreadsheet and we track denials for other purposes. We track denials to ensure that insurance companies are not bullying our offices. So if we see that Cigna is now incorporating the payment for buildup with the crown, we track that because if we're having a high rate of that happening, we are going to report that behavior to the insurance commissioner, and you guys know how I feel about getting the insurance commissioner involved. It is something that I wish we would do better with as an industry of dental billers. I wish that we would do that. I'm not talking about individual denials every single time, but I am talking about when we identify patterns of insurance bullying to the insurance commissioner, so that we can eliminate this type of behavior in our practice. I think that that's really important. But also I want to mention and I know I'm getting a little off track here, but I feel like I need to say this right now as an industry, we, as billers, we're not doing well with appealing our claims.

Speaker 1:

So one thing is to get the insurance commissioner involved and the other is to just appeal the denial, because a lot of times we don't have to get to the point of involving the insurance commissioner. A lot of times all we have to do is threaten to get the insurance commissioner involved. And a lot of times and I know this because I've trained our offices to call the claims processing department and inform them that they have received everything they need to pay a claim and they need to pay this claim in good faith. Otherwise we're going to report this behavior to the insurance commissioner. Almost 100% of the time they will process that claim right on through, because they don't want it to get to the point where we're reporting it. But, friends, even if they don't process that claim through at that point we can still follow through with an appeal and a lot of times I find that appeals work. You know, we appeal it once and we're able to get that claim paid.

Speaker 1:

But the problem is that every year when I read the state of claims report that Experian releases annually, the appeal percentage is still very low and that tells me that we are not appealing denials. And I think the 2024 state of claims report said that 59% of denials for 2024 were upheld, mainly due to the fact that most billers are not appealing their denials. And I get it. We have a lot of things that we have to do during the day, but denials have to be managed. It's called denial management, my friends, and it has to happen. So if we're not monitoring denials going back to my point here if we're not monitoring denials, if we're not monitoring things and how our insurance companies are treating us, you can rest assured. They are monitoring you and they are looking for ways to issue clawbacks. They are looking for ways to ask for money back. Ask for money back and we need to get better at defending our office and protecting our office from things like a clawback.

Speaker 1:

Do not resubmit a denial with a different code because it sounds good. I was recently asked by a coworker if it's okay to bill for D2335, and, if that gets denied, to resubmit it for 2390. My immediate thought when I was asked that question was well, what does the clinical documentation say? Because if the clinical documentation states that we did a four-surface anterior composite filling, as we initially submitted with that claim, and then that gets denied, but then we turn around and bill 2390 for a resin-based composite crown, which, by the way, also requires all five surfaces to be involved in order to get paid for that composite crown, but if you have clinically documented M-I-L-F on number eight and that gets denied and then you resubmit for a clinical crown but that doesn't match your documentation, you're committing fraud. There's no way to sugarcoat that. This is being instructed by the doctor. So I understand that we want to get paid for the things that we're doing, but there is no excuse to the law about you getting paid too little or this is an unfair denial.

Speaker 1:

Show me the appeal that you did, unfair denial. Show me the appeal that you did. Show me the report to the insurance commissioner that you made. Or did you just decide you were going to submit a new code? And these are the things that the insurance companies are tracking.

Speaker 1:

Like I said in the beginning, you may think you're not going through an audit because nobody has said anything to you, but insurance companies are not going to tell you until they've built their case. These audits that are conducted for compliance purposes like when you get informed that you need to pull 25 charts so that the representative from the insurance company can review them and go through the software and look at the clinical documentation those are compliance audits. Those are not triggered as a result of your office being flagged as high risk. However, through the compliance office I'm sorry, through the compliance audit you can be flagged as a high risk office if they start to uncover one thing after another Because through these compliance audits that are required they are required for accountability purposes to conduct compliance audit. Compliance audits do not mean that you did anything wrong. It just means they're they are doing what they have to do on their part, on the insurance part. However, through that compliance audit, if we are not on the up and up with HIPAA, with anti kickback statute, if we are not on the up and up with a breach policy, if we're not conducting our HIPAA, annual HIPAA trainings, we can find ourselves in deeper waters than we want to be.

Speaker 1:

I wanted to create this episode so that we can create awareness around how, as fillers, we can do better. So one of the things that I encourage you to do after listening to this is go back to your office. If you are a dentist and you're listening because I know a lot of dentists do listen to this podcast and shout out to my doctors because you guys make it happen and none of us would have a job without you. If you are a dentist and you have not conducted a HIPAA annual HIPAA training, send me a message. Hipaa annual HIPAA training. Send me a message. We do these trainings at no charge for our billing clients. But if you are a listener of this podcast, reach out to me and I will have you join our free annual HIPAA compliance training as a token of my appreciation to you for following us here on the podcast. Because, trust me, friends, my team and I do a lot behind the scenes in order to support this podcast. We do our best to put out as much relevant information as we can so that you can do better in the office. So here are my final thoughts on this episode.

Speaker 1:

Insurance companies are looking at everything. They're tracking your claim, adjustments or resubmissions, as we talked about it. They're tracking refunds. They're tracking all of these things behind the scenes. If you are changing codes to get paid, you're not risking just an audit, you're risking an entire practice. So be careful. If you need help protecting your office from billing mistakes or you want a free risk assessment, reach out to me and we will hop on a call and we can do that free risk assessment for you. I have yet to find an office that fully passes our risk assessment, so maybe you are that office, but we won't know unless you hop on a call with me and we go through our risk assessment together. So, with that being said, I think the worst mistake you can make is assuming that insurance companies are not watching, because they are, and what I want you to do is take control before they see that you are out of compliance. With that being said, I will see you in the next. Bye for now.

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Ericka Aguilar

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