The Dental Billing Podcast

Outsmarting AI: The New Dental Claims Game

• Ericka Aguilar • Season 11 • Episode 3

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Artificial intelligence has quietly revolutionized how dental insurance claims are processed, and most dental offices don't even realize it. Today we pull back the curtain on Novo Dynamics and their Novo Health Dental AI system that's scrutinizing your x-rays, documentation, and billing patterns before a human reviewer ever sees your claim.

The game has changed dramatically. Insurance companies have trained AI systems to review claims using very specific criteria determined by their own dental consultants—not treating clinicians. These systems don't just look at individual claims but cross-check x-rays across multiple insurance carriers, analyze your practice's billing patterns, and compare you to other providers in your area. If your practice performs more crowns, SRPs, or implants than what AI considers "average," all your claims face increased scrutiny regardless of their legitimacy.

This technological shift demands we evolve from merely submitting "clean claims" to creating "AI-proof claims." High-quality, clear x-rays that perfectly demonstrate necessity, concise standardized narratives, and meticulous documentation are no longer optional—they're essential. When AI improperly denies claims, request human review promptly. Document patterns of improper denials and report systematic issues to your insurance commissioner. The days of assuming a person will review your claim are over, but by understanding how these systems work, you can adapt your strategies to overcome these new barriers to reimbursement.

Ready to level up your billing skills and connect with fellow dental billers? Join us for our upcoming live workshop in Dallas! Send "Dallas" in a direct message to @dental_billing_coach on Instagram for your chance to win an all-expenses-paid trip to the event. Looking forward to diving deeper into AI and dental billing in our next episode where we'll share real-world denial stories and more strategies to beat the algorithms at their own game.

Want to learn Dental Coding and Billing? Join here:

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Would you like to set-up a billing consultation with Ericka? We would love the opportunity to discuss your billing questions and see how Fortune Billing Solutions may help you.

Email Ericka:
ericka@dentalbillingdoneright.com

Schedule a call with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min


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:

Hey, fellow dental billers, welcome back to another episode of the Dental Billing Podcast. We are your go-to source for all things coding billing and lately it feels like a little insurance drama. We're gonna talk about that today. If you are new here, I wanna welcome you, and if you are one of my loyal listeners, seriously, you guys are the heartbeat to this show. I appreciate every message, every question and every story that you share with me. I want to give a huge shout out to April from Baghdad. April is holding it down overseas supporting her military husband while doing remote billing. So, april, you are amazing. And to your husband, thank you for your service and everything you do for our country. We appreciate you both.

Speaker 1:

Okay, before we dive into today's episode, I have an exciting announcement. We are officially planning our next live dental coding and billing workshop in Dallas, texas. And guess what? You're going to have a chance to win an all expense paid trip to the event and we get to have dinner together. So you'll join my team and I for dinner. And how you're going to enter is by going over to my Instagram page. You can find me at dental billing coach. So it's dental underscore billing, underscore coach, and you're going to send me a direct message type in the word Dallas, and that's it you will be entered to win a chance to join us at the live event in Texas. Of course, one of my team members is going to ask you for some additional information, but that's how you're going to get the entry kicked off is by just sending me a quick message on Instagram type in the word Dallas, and hopefully you will win an all expense trip out to the event and dinner with my team and I and whoever else wants to join us. I usually have a group of five to 10 people from the event that typically I go to dinner with afterwards. It's really fun.

Speaker 1:

Okay, so in today's episode, we're going to call this a mini masterclass on artificial intelligence, ai and dental claims and what's happening behind the scenes. So if you are new to dentistry, this is the way it is going to continue with the landscape around dental billing. If you have been in dentistry, like myself, for almost 30 years, or maybe you've been in dentistry for like 10 years, this is still new to all of us. The world of AI is here to stay and I want to talk to you about how our claims are being processed on the back end. Now with artificial intelligence, let's go.

Speaker 1:

Have you heard of Novo Dynamics? No, well, allow me to introduce you to the reason your claims are getting flagged, your x-rays are under more scrutiny than ever, and why insurance companies are suddenly asking for things like a five-year perio history or something like what we saw recently a patient's last menstrual cycle. Novo Dynamics is the company behind Novo Health Dental. It's an AI system that many of the insurance companies you're billing today now use to review, approve and deny claims before a human ever gets a chance to look at them. What is Novo Dynamics and Novo Health Dental? Novo Health Dental is an AI-driven claims review system used by insurance companies, not dental providers, because I know there's AI out there that helps us to improve clinical necessity and prepare that for claims, giving you a higher chance of getting paid.

Speaker 1:

This is not that type of AI. Novo Health Dental works with insurance companies to scan your claims, x-rays and documentation before a human gets to them. This AI is trained to determine if x-rays meet the expected criteria for a procedure. I've referred to that as payment processing policies, but this is deeper than that. This is the AI getting trained by insurance company dentists and training them on what an x-ray should look like for a crown, as an example. This AI is also flagging high risk claims and whatever that insurance company defines as a high risk claim. This artificial intelligence is going to flag it, and it's usually based on provider history and the provider's coding trends. It's important that you know we are coding for what we're doing and there is not a sudden spike in the use of a specific code because that could flag your claims as high risk. It also cross-checks claims across different insurance carriers to catch duplicate x-rays, and I'll talk about that a little bit later in the episode.

Speaker 1:

But there's a lot that insurance companies are taking into consideration in order to determine, approve, deny, flag, high risk fraud. They are taking so much information outside of the claim, using metadata in order to determine if your practice is a high risk practice, and I'm going to talk to you about some of the metadata that they are using in order to classify your office and friends. You've heard me talk about this before in the past, but using the power of the insurance commissioner is another tracking tool that insurance companies are using to classify and label your practice. So just like they will label you a high risk practice, they will also label your practice as that office that blows the whistle when you are reporting illegal behavior, unethical behavior, improper denials to the insurance. Commissioner, we're going to incorporate a little bit of that into this conversation.

Speaker 1:

Let's talk about how we, as dental practices, dental billers, how we can AI proof our claims from the start. So we're going to start off with what we've always talked about, right, we've always talked about submitting strong, clean claims so important that we do that and that's just one layer as to what is being monitored. So we don't want to give the insurance company an excuse to deny our claim. But if we take that up one notch now we're talking about AI proofing our claim we must. There's no longer room for error. There's no longer room for error. There's no longer room for not capturing a high quality x-ray. Ai is trained to look for certain things and if we give a blurry x-ray and AI cannot see what it was trained to look for, it will get denied. So we have to level up with the quality of x-rays that we are submitting because we want to make sure that Novo Health Dental Artificial Intelligence can see what it's looking for.

Speaker 1:

We also want to make sure that we are using standardized narratives, and I don't mean a bunch of templates, though I love templates, I love a good template that helps save some time, increase productivity I love that. But I'm guilty of this in the past where my narratives have been too long, and now that we have artificial intelligence coming into play, we have to really tighten those up, reduce the verbiage, get to the point and use clear, industry standard explanations. So, if you are submitting a narrative that is longer than, say, 80 characters, I would then create a Word document and submit that narrative as an attachment Even better to AI proof my claim. I'm gonna try and get directly to the point with specific industry standard explanations, like for buildup, using the term retention very quickly in my narrative, buildup needed for retention purposes period. I got straight to the point and I'm sure you guys can shorten that up a little bit more as well. So you know.

Speaker 1:

The point here is we are not only talking about submitting clean claims. We are now talking about AI proofing our claims, and it's a whole other ball game. Don't assume that your claim is going to be seen by a person, because most likely, moving forward, we're going to have to request human review as needed, and that's going to be. When we feel like artificial intelligence isn't budging and maybe they're upholding a denial that we know is improperly being upheld, we're going to want to fight back and we're going to want to ask that a human review your x-rays or your claim, and if that still doesn't work, then we're going to go down the path of getting the insurance commissioner involved, and that's a whole other conversation that we've had in the past. So if you are interested in learning more about how to incorporate the insurance commissioner into your billing practices, let me know, send me a message and we'll have a big, long chat about that.

Speaker 1:

All right, ai is changing how claims are getting denied, as I mentioned earlier. Let's talk about that a little bit, because who taught AI what necessary treatment looks like? Well, as I mentioned earlier, let's talk about that a little bit, because who taught AI what necessary treatment looks like? Well, as I mentioned earlier, ai is trained by insurance company dentists, not your dentist, right? So these are the guys on the other side of the court, and that means that AI is not programmed to approve claims. It's programmed to scrutinize and deny.

Speaker 1:

Did you hear me? Scrutinize and deny? We are already scrutinized to the max, but AI is going to take it up to a whole other level. If AI doesn't think your x-ray matches what it was trained to expect, your claim is going to be denied. And yes, friends, you can hear the little feisty Latina in me right now because this annoys me. This really annoys me that we are already scrutinized to the max and we're already dealing with improper denials, but now we have artificial intelligence coming into play and it is being taught to take the denial game to the next level. So I am creating this episode because when I learned about Nova Health Dental and how it is being programmed to scrutinize and deny and it doesn't say that in those words, but if you read between the lines, that's what's happening. So I really want you to level up as billers and AI proof your clean, valid claims so that we can get ahead of some of the challenges that we're going to face here.

Speaker 1:

Okay, so if you get a denial that says the x-ray does not support necessity of treatment, it is because AI is not seeing enough damage or bone loss, and it's very important that we also understand. That does not mean that you did not submit an x-ray that proves dental necessity. It just means that AI did not see what you saw or what you sent in. So that is the perfect time to call the insurance company and ask for a human to review your claim. How do you know if your claim was denied by AI or was it denied by a dentist reviewer or a human? The EOBs are giving crazier and crazier reasons for denial or delay or additional information, but the real reason is we are being cross-checked across multiple insurance companies. So you're submitting a claim to MetLife, but they are going to cross-check that claim across multiple insurance plans. They are going to cross-check it against all the other millions of claims that they have on file. And this is happening in seconds, right? So they are cross-checking, checking all that other metadata, and that's how they are coming to their conclusions.

Speaker 1:

It is no longer just based on your standalone claim. Ai is not trained by your treating doctor. It's trained by the insurance company dentist. This means it's programmed to look for very specific characteristics before it can approve a claim. If AI does not detect what it was trained to expect, the claim is denied or it will be flagged for additional information. It's looking for bone levels for perio treatment, tooth structure for crowns, post-op images for endo claims. This doesn't account for clinical judgment. Ai is not taking that into consideration. So if your doctor sees a crack but AI doesn't, that claim is going to get denied. Or the angle AI expects is not there, it's not going to recognize the issue and some conditions don't always show clearly on x-rays right, like microfractures, early decay or certain perio cases.

Speaker 1:

It's important that we give the insurance companies everything we can possibly give them and, if AI denies a claim due to lack of necessity, just request a manual review. Remember, ai doesn't just look at individual claims, it's tracking billing patterns over time. So here is what AI is monitoring it's monitoring how often your office bills for certain procedures, whether your provider bills more crowns, srps or implants than other dentists in your area, how frequently a single patient is receiving certain procedures, and this is why this can be a problem for us. If your office is a higher than average number of SRPs or performs a higher than average number of SRPs, crowns or implants, ai might flag your provider as an outlier right. So we want to make sure that we're still reporting what we're doing, but we can prove to the insurance company that we are simply treating what is coming into our practice right.

Speaker 1:

Insurance companies like to have a reason to delay payment or deny, and these are all those meta data pieces that they're looking for in order to do that, in addition to that individual claim that you've submitted. This means that your claims can get flagged for review more often, and that's just going to lead to more delays, denials and extra work for you as the biller, or, if you're the doctor listening to this, it's just going to lead to more work for your team. So how are we going to fight back? We want to track our denials, track the increase in flagged claims, like the claims that are requiring more documentation. I want you to flag the request for additional documentation claims. I want all of that tracked because these are behaviors that are turning into patterns and those patterns need to be reported to the insurance commissioner. If there's one thing that I want you to take away from this is, friends, we still need to get better at appealing our claims.

Speaker 1:

Before you can ever approach the insurance commissioner for help with any of these delay and denial tactics, you must first give the insurance company an opportunity to correct an improperly denied claim. That is requirement 101. Before approaching the insurance commissioner to report any type of behavior, you always have to give the insurance company an opportunity to correct it. Now you give the insurance company an opportunity to pay the claim that the patient has benefits available to them for if that made sense, you will appeal and they deny that appeal. Now you have the right to go and document and report that behavior to the insurance commissioner because ultimately, on their end of the court, they're trying to keep dollars in their pockets. They're not going to admit that right. They're just going to say these are the parameters that are in place. You know this is what the employer designed for this plan and yada, yada, yada. But the idea truly is for the insurance companies to keep dollars in their pockets while continuing to collect premiums from the patients, and there are laws around collecting premiums and a percentage of claims that have to get paid in order for that insurance plan to be compliant. So we want to monitor all of these behaviors and go through the proper channels in order to get better outcomes.

Speaker 1:

Now I'm gonna go back and reiterate something through the proper channels in order to get better outcomes. Now I'm going to go back and reiterate something you need to first level up with your clean claim submission game before you can AI proof your claim. That sounded a little redundant, I heard myself. However, I want to emphasize that if you are receiving denials because you're submitting weak claims, then none of this applies to you. You first need to stop giving insurance companies a reason to deny your claims, because I know I'm always harping on the insurance companies and I'm always talking about how they deny, deny, deny which I do see right but I also see that there are a lot of lazy billers out there that are moving too fast or they're just not caring enough to get the claim paid. Whether it gets paid or not, either the insurance is going to pay it or they're just going to push that balance over to the patient. I am talking about those of you who are already submitting clean, valid claims, and now we on this side of the court have to level up again and AI proof our already clean, valid claim and make sure that we are removing any excuse that artificial intelligence can potentially give to deny our claim.

Speaker 1:

And I think this is going to boil down to the procedures that require x-rays or require some proof of dental necessity or require some proof of dental necessity. And so, taking a better look at the x-rays that you are submitting, training your clinical teams to take better intraorals, to take better x-rays, get that CT, get that pano. We really have to get good at getting high quality attachments so that we remove the insurance company's ability well, I wouldn't want to say ability, but decision to deny that claim because now we have a stronger fighting chance of getting help from the insurance commissioner. So it's all connected. It's like a little ecosystem of bulletproofing AI proofing your claim. All right.

Speaker 1:

So let's talk about what AI is cross-checking your claims against different insurance carriers to catch duplicate x-rays. They're looking for fraud. They're just looking for a ton of stuff. So if a patient has multiple insurance, like dual coverage AI cross-references x-rays between carriers to check for potential fraud. So here's what they're looking for. They're looking to see if the same x-ray has been used for different claims across multiple payers. They're also looking to see if the same x-ray has been used for different claims across multiple payers. They're also looking to see was the x-ray taken on the same date but submitted under a different claim? Right, like that just blows my mind that they even think to look for this stuff, but I know that this happens and has this x-ray been altered or resubmitted in a different format.

Speaker 1:

Really important to know that AI is checking all of this as it is processing your claim, and here's why this can be a problem. Legitimate claims can get flagged just because an x-ray was used on multiple claims. If a patient has dual insurance, ai might mistakenly assume that duplicate x-rays I'm sorry, duplicate claims equal fraud. So we are now going to have to go and fight those battles in proving that this was not fraud. This was a dual insurance case. It could be a legit claim flagged for fraud because the patient had dual insurance. The only fighting chance that we have is to make sure that we are submitting the best quality x-rays, attachments, narratives, narratives, all of the things and make sure that we are submitting the strongest, cleanest valid claim that you could possibly submit. This is just the beginning, friends.

Speaker 1:

As AI continues to get smarter and learn how to adjudicate claims. The game will change over time, but ai is still new. I know that, um, we have been using artificial intelligence in claim adjudication for years I want to say at least a decade that the insurance companies have been using. I know novo Dental has been around for 20 years. They have been using this type of technology for years. It is now becoming more mainstream and they're using it to its fullest potential.

Speaker 1:

Go check out Novo Health Dental. It offers some really insightful information as to how your claims are being processed on the back end with artificial intelligence. So it is just fascinating to me that this is happening and for those of you that are new to dental billing, this is going to be the norm for you. For those of us that are, I would call us oldies but goodies.

Speaker 1:

I've been in the dental billing game since 1998, you know when billing was still done by hand and we submitted everything manually with the good old envelope and stamps.

Speaker 1:

There was no electronic claims.

Speaker 1:

We had to duplicate our x-rays to send them off because we couldn't send the original x-ray.

Speaker 1:

You would just never get that back in most cases. So it's definitely gone from archaic manually filling out those claims back in 1998 to what it is now and moving into this new era of artificial intelligence, also moving into a new coding era of utilizing your diagnosis codes and so much more. It's just getting better and better. So I hope that this episode helped open your eyes on what is happening and how your claims are being processed on the back end, because I see a lot of people reporting some really funny EOB explanations as to why claims are getting denied, and the funniest one that I've seen so far is requesting for the patient's last menstrual cycle. So if you have an AI denial horror story, send it over my way and I would love to share some real cases with you in the next episode. I will see you in the next episode. We're going to dive deeper into the world of artificial intelligence and how to beat AI at the denial game. See you in the next episode, friends.

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Ericka Aguilar

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