Episode 81: Are you a Backyard Biller or a Billing Expert?

Dental billing has undergone a dramatic transformation since the carefree days of the late 1990s. What was once a straightforward process—send a claim, get paid, move on—has evolved into a complex system demanding meticulous attention to detail and strict compliance measures. The reason? Insurance companies have woken up to the staggering $12.5 billion lost annually to dental fraud, and they're scrutinizing claims like never before.

You don't need to be committing actual fraud to get caught in this web. Cutting corners, skipping steps, and clinging to outdated "backyard billing" habits can quickly put a target on your practice. Are you submitting claims without checking clinical notes? Skipping attachments to get claims out faster? Using coding loopholes that worked a decade ago? These practices aren't just inefficient—they're potentially putting your practice at risk for denials, audits, and recoupment demands.

True billing expertise isn't defined by years of experience but by commitment to compliance and continuous education. It means verifying clinical documentation matches what you're billing, understanding dental necessity requirements, staying current with coding changes, and implementing robust follow-up systems. It means knowing when to push back when insurance companies request additional information despite receiving sufficient evidence the first time. Most importantly, it means understanding your state's prompt pay laws and holding insurance companies accountable when they attempt to delay payment beyond legal timeframes.

The transition from backyard billing to compliant billing isn't complicated, but it requires intentionality. Start by implementing daily report monitoring, creating standardized billing protocols, and ensuring your team understands compliance requirements. The reward? Fewer denials, faster reimbursements, and significantly less stress from chasing payments that should have been received the first time. Remember: the goal isn't just getting claims paid—it's getting them done right.

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Perio performance formula:

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

Delta Dental Locum Tenens Form:

https://www1.deltadentalins.com/content/dam/ddins/en/pdf/dentists/locum-tenens-form.pdf

Transcript

Recognizing Backyard Billing Habits

Speaker 1 0:54

with my fellow dental billers in mind. As you know, I have been doing dental billing since 1998, and I've seen it go through so many changes. I have seen the relationships between insurance companies, with all of the ups and downs that we have seen in the contract, language coding changes, payment processing policies changing annually. There's been so much to keep up with. Back in my day, billing was easy Very little attachments, and if we did need an attachment we would duplicate the x-ray, send the x-ray off in a little coin envelope. The narratives were simpler and the denials weren't soul crushing to the extent that it made you question your career choice. You simply sent a claim and it got paid and you went on with your life. Those days are dead and gone. Insurance companies got woke. If you're still billing like it's the early 2000s, you're basically setting yourself up for a world of denials, audits and the good old please resubmit with additional information, and nobody has time for that.

Dental Necessity and Documentation Requirements

Speaker 1 2:13

So here's a hard fact association Dental fraud costs insurance companies and consumers about $12.5 billion every year. You don't have to be out here committing actual fraud to get caught up in this mess. It's things like cutting corners, skipping steps and backyard billing habits that will put a target on your back really quick. So, for the sake of a wake-up call, I want you to think about a couple of things. Are you submitting claims without checking clinical notes, whether or not that procedure requires an attachment? You still need to read the clinical note because you want to make sure that the prophy that is being charged out on the patient's ledger or account is actually documented for, because we are always checking for clinical documentation matching what's placed on a claim form. So if you are not doing that, let this episode be your reminder that we need to check clinical notes. What about skipping attachments just to get the claim out faster? I've seen a lot of that where we're moving too fast and we're skipping steps because we are not slowing down to verify that we are submitting a clean, valid claim. And finally, have you been guilty of resubmitting an FMX as bite wings and PAs just to get paid for something? That's backyard billing and it is going to give audit waiting to happen kind of vibes, and I don't want you to fall into this trap. So if this episode makes you sweat a little bit, I don't want you to worry because I got you. I'm going to break down the biggest billing mistakes that I see and what separates an average biller from a true expert. Compliant billing is not optional, and it's the key to maximizing insurance payments, reducing stress and ultimately protecting your practice and ultimately protecting your practice. Let's talk about what backyard billing actually looks like in the wild.

Speaker 1 4:48

If any of these sound familiar, it's probably time for you to rethink how you are doing things. Number one is submitting claims without reading clinical notes. I see this often and I have a lot of conversations with dental billers who have 20 years under their belt 10, 15, five years. The point is, they have experience and they are reaching out to me because they heard, either on Instagram or my TikTok, that you need to read clinical notes, and they will reach out to me and say I've never thought about reading clinical notes. I usually just bill what they post or what they set complete. It is so important that we are verifying that the procedures that are being charged out are matching what we are putting on a claim form, and I do consider not reading clinical notes a rookie move. So make sure that you are in fact, billing for services that are documented and done. Number two is skipping attachments for procedures that require them, also verifying that you are submitting an attachment that is of diagnostic quality, meaning that there are no cone cuts, it's not foreshortened, it's not elongated, it's not blurry, it's a great x-ray that gives sufficient evidence proving dental necessity.

Speaker 1 6:36

So I'm going to pause right there and let's talk about dental necessity and what that means. The definition, in short, of dental necessity as a filler and how we need to understand it is restoring form and function of a tooth. When we are submitting an x-ray or an attachment, we are proving to the insurance company giving them sufficient evidence to pay that for that procedure that we are in fact restoring form and function. So when your buildup gets denied and they want to include payment for buildup as a part of the crown, we needed to do the buildup in order to restore form and function to that tooth and that's why we give them an intraoral photo. That is pre-buildup right. So I always tell my assistants if you are doing a buildup, we are having to prove dental necessity in excess of a narrative or an x-ray. So I like to have a pre-buildup, post-decay removal and submit that with the claim, thereby giving them sufficient evidence of dental necessity, right.

Eligibility Verification and Coding Updates

Speaker 1 8:24

So that step often gets skipped because we're not slowing down to ensure that we are submitting sufficient evidence to prove dental necessity and sometimes we have to prove medical necessity. Sometimes there are other factors that go into why we are doing SRPs. So we want to make sure that we're slowing down. If a patient is on blood thinners, obviously we can't bring that patient back two weeks after the first two quads. We would have to prove to the insurance company that we had to do all four quads because the patient is on blood thinners and that would prove the medical necessity behind why we had to kind of go against the frequency grain that they imposed on us. So skipping steps for procedures that require them is a biggie. That I see as well. If you're not including x-rays or a complete perio chart, you are giving the insurance company a reason to then ask for their money back. If they do an audit back seven years looking for reasons to ask for money back, they are going to then say this was an incomplete perio chart. We would like our money back for that, because you didn't submit sufficient evidence proving medical or dental necessity for that procedure.

Speaker 1 10:05

Really, really important that you are taking a moment and reviewing the attachments that are required to get some of these larger procedures paid. Now I'm going to kind of go off the topic, but it's still on topic. I talk to dental teams all the time and one of the things that we like to do is train our back office staff to understand which attachments are needed for the procedures that we do the rocks right of the procedure family. I'm not sure how many of you are familiar with the rocks, pebbles and sand theory when we're talking about appointment scheduling, but I do use that term and I use those that same analogy when I'm training a back office team on what we need for our ROC procedures. So, like for a crown, this is what the x-ray needs to look like, and if it's older than this then we can't use that x-ray. I want all of my assistants to understand that, because billing starts in the back. So taking time to get ahead of that challenge. If you're an office that is having some challenges with attachments or intraoral photos or blurry x-rays, I would certainly spend some time with your clinical team so that they can help us on the billing side, on the billing end of it. Super, super important.

Speaker 1 11:48

Not verifying number three. Let's go into number three. Not verifying eligibility before treatment. If any of you have ever worked with me, either in an office, because I know shout out to my co workers that have worked with me for many, many years. If you know me and you've worked with me in an office, you also know that nothing drives me nuts than getting a denial due to frequency or due to ineligibility. I'm not talking about those instances where a claim gets paid and then the insurance company requests the money back because the patient wasn't eligible at the time of service, even though we have verified eligibility. That's a whole other topic and there are reasons why that happens that have nothing to do with the eligibility, but have everything to do with the employer using a different insurance company and not paying their premium. It can get really messy. Let's just put it that way and, if you want, I can do an episode on that. But going back to not verifying eligibility ever in the first place, there's nothing worse than billing for treatment that a patient's insurance won't cover because nobody checked. That's just unacceptable, okay.

Speaker 1 13:17

Number four is using what worked before instead of actually following the rules. If your billing strategy is based on loopholes that worked in 2010, you're playing yourself. That worked in 2010, you're playing yourself. Insurance companies update their policies constantly and they will catch on to these patterns. So make sure that you are updating your knowledge. You're updating your codes. I work with offices all the time and I do have to say a lot of you are not investing in purchasing the CDT book. Every year, codes are being revised, they are being deleted and we are getting new codes and we're also getting new categories of service.

Speaker 1 14:09

If you are not on top of your game, then how are you going to consider yourself an expert If you have not updated your knowledge, as it is changing annually? How do you consider yourself an expert? Just because you have 5, 10, 15, 20 years of billing under your belt does not make you an expert. So don't call yourself an expert if you are not updating your knowledge annually. Experience does not matter in the billing arena because sometimes, if you're going based off of old what used to work, sometimes that could hurt you by causing delays or denials. So make sure that we are not using the what worked before method. We are using the follow the rules and update your knowledge method annually. How about that? And update your knowledge method annually. How about that? Okay, ignoring number five is gonna be ignoring clearinghouse rejections or delays.

Claiming Like an Expert

Speaker 1 15:18

Friends, you have to check your clearinghouse reports but, more importantly, you have to also verify that the claims are actually making it over to the insurance companies. Because we do AR cleanup and we're pretty, we have a pattern down and one of the things that we see most prevalent in all of our cases that we clean up is that the claims that are the oldest typically have not made it over to the insurance company. If you go back to the clearinghouse and you look at the report, the report says that it was sent over to the insurance company, but the insurance company, for some reason, it, never made it over. So your claims are in limbo and nobody's checking on them. Congratulations. Now you have a cashflow problem, right? Because nobody's checking on whether or not the claims actually made it to the insurance company. And I know that that sounds like it's an extra step, because it is, but it's an extra necessary step because we cannot rely on the reports from the clearing houses 100% of the time. It is just one of those things where there's no getting around going directly into the insurance portals to verify that your claims have actually made it through.

Speaker 1 16:57

That is number five. And if you're guilty of one or all of these things I don't want you to stress out. We're going to talk about it and we're going to talk about how to fix these issues. Here's how you can level up and start billing like an expert. The first thing you're going to do is start verifying clinical documentation before submitting any claim. It's the oldest rule with billing right If it is not written down, it didn't happen. Make sure that the provider's notes actually support what you're billing for. It is so important because we don't want to unintentionally commit fraud. We can do that. As I mentioned earlier, you don't actually have to be actively committing fraud, knowingly committing fraud. You can accidentally commit fraud for billing for something that was never documented right, so it can be viewed as billing for things that weren't done for financial gain, and we don't want to do that. So verify your clinical notes.

Speaker 1 18:04

Number two is use your correct coding and CDT guidelines. Your correct coding and CDT guidelines. Please stay up to date on CDT changes, because I didn't know that code changed or I didn't know that that code is no longer valid is not a valid excuse for a denial. It's just not going to be acceptable. I recently spoke to a biller who asked me if nightguards are no longer covered by most insurance plans because her nightguards continuously get denied. So I asked her what code is she using to bill the nightguards, because no nightguards are still a covered benefit? And she said 9940, d9940. And for those of you that know, you know that that code was replaced and deleted quite a few years back. So it has been causing denials for all of their nightguard cases, been causing denials for all of their night guard cases and they've been charging their patients because they would have been using the wrong code. So that's just one example of the kind of conversations that I have with my Instagram followers, with my TikTok followers, with people on LinkedIn. I have coding conversations every day, multiple times a day, about which code they should use for which purpose. Now there are so many resources out there that I recommend, but the biggest resource that I recommend is the CDT book. Resource that I recommend is the CDT book. Going and purchasing that CDT book every year because of all of the changes.

Speaker 1 20:00

So that is how we are going to level up, one of the ways that we are going to level up with our billing. Third way is we're going to attach necessary supporting documents and we're not going to give the insurance company a reason to deny our claim. We want to make sure that everything is accurate as we are submitting it or before we submit that claim. We want to submit a clean, valid claim. And here's why, when we submit a clean, valid claim and the insurance company then sends that good old, I want more information, more documentation, more information, more documentation. We are going to tell them that we submitted sufficient evidence to pay this claim in good faith or we are going to report this behavior to the insurance commissioner?

Following Up and Understanding Prompt Pay Laws

Speaker 1 21:00

If you haven't already listened to my episode about using the power of the insurance commissioner, I will put a link to that episode about using the power of the insurance commissioner. I will put a link to that episode in the show notes because, friends, it's powerful when you push back on these types of requests. However, the caveat again I'm going to mention this is that you know you submitted a strong, clean claim. You know that your x-rays show dental necessity right, we're restoring form and function. You know that you gave them an intraoral of that tooth having less than 50% tooth structure, thereby needing a buildup in order to retain a crown.

Speaker 1 21:46

We know we submitted all of that information and, no, we are not going to provide additional information. We gave you sufficient evidence proving dental necessity. Pay this claim in good faith, as you are supposed to, or we will report you to the insurance commissioner. So when you know that you have attached necessary supporting documentation and you are a clean claim king or queen, you know you are submitting those claims in the proper fashion and you know that the insurance commissioner would have your back on this claim friends, you are going to pick up the phone and you're going to call the insurance company and you're going to say we submitted sufficient evidence proving dental necessity and you guys need to pay this claim in good faith or we are going to report this to the insurance commissioner.

Speaker 1 22:43

A lot of times and this has been told to the many, many billers who I have trained to do this when you call the insurance company and you let them know that you are not going to be submitting additional documentation because we gave you sufficient evidence right, then they will process your claim in most cases. Then they will process your claim in most cases. We are not going to play the additional information, delay in payment game, because that's all that is designed to do is to delay your claim. So we are not going to do that. And if you didn't know how to play that game before you, listen to this episode. Now you know. And if you need more verbiage or you want more of a script, I'm happy to share with you what I give to my offices when we're training them for follow-up, claim follow-up strategies. We don't play that game.

Speaker 1 23:45

This is why it is so important to have follow-up strategies in place, like verifying that all of your claims have actually been received by the insurance companies. This is why it is so important that somebody is logging into these insurance portals and verifying the week's claims were actually received by the insurance company. Follow up Friday, friends. Follow up Friday. Fridays are the days when I'm logging into the insurance portals and I'm verifying that our claims for the week were actually received, and you'd be surprised how many times I am resubmitting claims that I thought went through by the clearinghouse, never actually made it over to the insurance company, and then we end up with an AR nightmare because we have zero follow-up game implemented into our weekly billing tasks, right?

Speaker 1 24:53

So want to make sure that we have follow-up protocols in place Now. How else are we going to level up Now? How else are we going to level up? We are going to make sure that we understand our state's prompt pay laws and you're going to start holding these insurance companies accountable as a biller. You need to understand your state's prompt pay law. Need to understand your state's prompt pay law. Every state has a different time frame in which insurance companies are held accountable by the insurance commissioner and, for those of you that understand this on a deeper level, please know that I'm trying to explain this in a way that everybody can understand. I know there are many layers of accountability, but I'm trying to make sure that my fellow dental billers understand that your state's prompt pay law is going to vary, so don't go sharing in the Facebook groups about.

Speaker 1 26:01

You know insurance companies have to pay by law. They have to pay within 30 days. That may only apply to your state, because there are other states that get up to 60 days. So we want to be careful that we understand our prompt pay laws according to your state, and we want to understand how to hold these insurance companies accountable, and that's going to be again utilizing the power of the insurance commissioner. So, understand your state. Just type in your state prompt pay law and it'll pop up. You can go to your state insurance commissioner's website. They have prompt pay information there. But as a biller, we need to understand that insurance companies only have a certain amount of time to pay or deny a claim. Anything that goes beyond your state's prompt pay time frame, prompt pay law time frame, then the insurance company owes you interest. So we want to make sure that we are holding them accountable and if they owe us interest because they're taking too long to make a decision on whether or not they're going to pay or deny, then you are going to bill them for that interest.

Transitioning to Compliant Billing

Speaker 1 27:26

I speak to a lot of really good billers and one of the traits, the common characteristics, if you will, of these billers that I have the pleasure of either working with inside of our billing company or just having conversations with is running reports on a regular basis. They are checking in with the clearinghouses and they are not letting claims age out of timely filing. Very, very important that we are monitoring and managing our claims efficiently. Shout out to the billers who are running reports on a regular basis and not letting things go beyond 30 days. How many times do you run your account receivable report? How many times do you look at just the insurance aging report. How many times do you look at your credit balance report? All of these reports play into our cash flow to the practice and, as an expert biller, your job is to ensure that there are no cash flow issues when it comes to your claims.

Speaker 1 28:46

Your claims cannot, 100% of the time, get paid within 30 days, but we can put a really hard push behind holding the insurance companies accountable to our state prompt pay laws. But we can only do that if we have proper management of our claims. So follow up. Another way that we can level up as a biller is to understand what it means to be legally compliant Understanding HIPAA, the HITECH Act of 2009, the False Claims Act, the anti-kickback statutes, knowing them, following them or getting caught up in them. Right Like that's going to be what an expert biller really understands and how this is going to apply to your claim submission. So if you get these steps down, you're going to have fewer denials, faster reimbursements and, I promise friends, less stress trying to chase the money that should have been paid the first time.

Speaker 1 30:01

Okay, so finally, I want to talk about how to transition from backyard billing to compliant billing. It's not a hard switch and now that you have been made aware about some of the ways that you may have picked up some backyard billing habits. We're going to talk about converting that, or transitioning over to being a billing expert who is a compliant biller. It's not hard, but here are three things you can do right now Start running reports daily and know what's missing before the insurance company tells you you may have missed a few things, but from this day forward, I want you to start running reports daily and verifying that you sent clean, valid claims with sufficient evidence proving dental necessities. I want that to be your mantra as a dental biller. I want you to submit clean, valid claims proving dental necessity so that the insurance company can pay your claim in good faith. Secondly, I want you to create a standard billing protocol. A checklist isn't just helpful, it's necessary, and we have one within our billing company, fortune Billing Solutions. We follow a billing checklist, and I also, finally, want you to download the free billing compliance checklist that we have created in order to make it easy for you.

Speaker 1 31:39

I want you to be confident that your claims can pass an audit, and if you are not confident, now is the time to get your billing life together. Go grab the free dental billing compliance checklist to make sure that your office is doing things the right way. And if you have any questions about your billing process, reach out to me. There's a link to connect with me in the show notes. I'd love to have a billing conversation with you and answer any billing questions that you have going on in your billing department. So, with all that being said, friends, I'm going to close out this episode with this quote. The goal is to get the claim paid, but it is also to get it done right. I will see you in the next episode. Bye for now.