The Dental Billing Podcast
Dental billing is not data entry. It's the difference between a practice that collects what it earned and one that writes it off and calls it the cost of doing business.
The Dental Billing Podcast is hosted by Ericka Aguilar and Jen Lyman, RDH. Ericka has been a dental biller since 1998 and has taught billing in 31 states and Mexico. Jen came out of the operatory and now runs Lyman Revenue Solutions, handling both dental and medical billing. One of us knows exactly what the carrier is going to do with your claim. The other one knows what actually happened in that chair. You get both.
Every week we break down denials, appeals, coding, and the carrier behavior nobody warns you about, in plain language, with real sources. We teach the law before the codes, because a code doesn't win an appeal. Knowing what that carrier is legally required to do wins the appeal.
If you've ever been told you're "just the biller," this show is for you. Downloads in 114 countries and counting. Bring your coffee and your worst denial.
The Dental Billing Podcast
Built to Get Paid Series - The Roles Map (Part Two)
Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.
Registration Link for Diagnosis Codes on a Dental Claim Form Webinar:
https://dentiqhub-diagnosis-codes.vercel.app/
Get your Dental Billing Toolkit Here:
https://www.dentalbillingdoneright.com/the-dental-billing-toolkit
Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:
Schedule a billing chat with Ericka:
https://calendly.com/ericka-dentalbillingdoneright/30min
Email Ericka:
ericka@dentalbillingdoneright.com
Email Jen:
jen@dentalbillingdoneright.com
Why This Podcast Is Human-Led
SPEAKER_00Every time I press record to record an episode for you, my listeners, I literally light up and I get excited. The research that is involved and the experience that I pull from is not generated with AI. We live in such an AI world right now. I feel like I'm going anti-AI. In a lot of parts of my business, I see a lot of content generated with AI. And sometimes it's just like downright obvious that AI wrote the content. Especially when you see content with all those emojis and those AI giveaways, it really bugs me. But I want you to know that majority of my episodes are not with us or created with AI. And when I say majority, sometimes I will ask AI for guidance on an outline, or sometimes I will ask AI to challenge my thoughts or to read my script. Because I still handwrite my scripts. I mean, I'm so old school, you guys. I still print out EOBs and mark them up with highlighters and pens, and I have different colored pens. You guys don't know this, but I love reading EOBs for fun. I know that sounds really, really nerdy, but I do that because I feel like I see patterns in a way that most people don't. And I like to take that information and teach you what I'm seeing. And because I do that, I get to pick up on not only the patterns, but the changes and the shifts in how insurance companies are processing our payments. And then I get to share that with you here.
The Role Clarity Test For Teams
SPEAKER_00So without further ado, we're gonna start this episode and we're gonna continue on our six-part series of the dental billing department framework that we use in order to restructure or build out billing departments. With that being said, I am genuinely curious. If I asked every person on your team what their role is in getting a claim paid, would I get 10 different answers? Or would I hear the same answer consistently across the entire practice? So I want you to pause and I want you to think about that before you answer. I want you to think beyond the title. I'm not asking who the hygienist is. I'm not asking who the biller is. I'm asking whether each person understands their responsibility within the reimbursement process. And they've probably never thought about it that way because those two things are very different. What I've discovered after helping hundreds of practices build, rebuild, and restructure their billing departments is that most offices have people, but they do not have clearly defined roles. And when roles are not clearly defined, accountability becomes ambiguous. And when accountability becomes ambiguous, things start slipping through the cracks. And I want you to hear this and hear this very clear. That is not because your people don't care. And it's not because they're lazy, but because nobody truly owns the outcome. You know, I'm a firm believer, and I say this in almost every episode, in treating your billing department like a business within a business. Every successful business has organizational infrastructure. Every successful business has an organizational chart. And your billing department should be no different. Today we're going to build the organizational chart for your billing department. Not because I want you to create more meetings, I want to provide clarity. I want you to identify where ownership exists, where it doesn't, and where the lack of clarity may be creating a dilution of results without you even realizing it. One person can 100% manage multiple roles. In fact, most small practices operate that way, but the role still exists, right? Whether one person wears three hats or three people wear one hat each, the responsibilities are still present. They still remain. And when those responsibilities are not clearly defined, predictable billing outcomes become almost impossible. So today I want to map out the billing department. So let's do that. We're talking about all of the roles within your billing department. We're not assigning people yet. We're just outlining the defined roles. So the first role is going to be the dentist, the next is the dental assistant, hygienist, the front office receptionist, the tracer, the biller, the poster, the ager, the compliance officer, and the manager. As we go through each role, I want you to ask yourself one question: Who owns this role in my practice? This is going to help create accountability. And accountability is what gets the needle to move, friends. I've said that forever. I always say that. Accountability gets the needle to move. So
Dentist As Liability Holder
SPEAKER_00let's talk about the very top of the billing department work chart. There sits the dentist. We refer to the dentist as the liability holder because whether they realize it or not, they're ultimately responsible for what is placed on the claim. The claim goes out under their license. The procedures were performed by them. The diagnosis originated from them, and the treatment plan originated from that diagnosis. Insurance companies are going to hold them accountable for the accuracy of that claim. One of the biggest misconceptions here is I don't do the billing. And while I understand what the doctor means when they say, when they say that, it's not really true. The doctor may not be entering claims into your practice management software and they're not posting the payments, they're not filing the appeals, but they absolutely participate in billing because everything begins with their clinical decision making. You can delegate the execution, but you cannot delegate the responsibility. And I that's a very important piece there because it is very important that we understand that what we put on a claim form needs to match the clinical documentation. Because if we accidentally add a procedure, let's say the patient was scheduled to come in for three fillings and the doctor only did two of those fillings, and we're just going based on what the patient was scheduled for, that's not going to match the clinical notes. And that's where unintentional fraud kind of seeps in. And I speak to a lot of fillers who to this day still openly admit to me that they don't verify clinical notes before they submit the claim. And that is scary for that doctor because if and when, I should say when you go through an audit, and I'm not trying to fear-monger here, you guys. I'm just stating facts. When you go through an audit, they are going to compare clinical notes to what they paid, right? So you want to make sure that you always and forever and 100% of the time are starting the process by verifying your provider's clinical notes. I say doctor in this case because we're talking about roles within the billing department. So making sure that what you're placing on a claim is backed up by clinical notes so that we minimize the liability that the doctor is absorbing through our efforts because what we do, they will be held accountable for. Doctors, you should understand the billing process. It should not be held hostage by one individual. And I mean held hostage because I've seen that happen where you have a biller who has full control, and there's some really, really bad practices happening within that billing department. Maybe the insurance AR is just out of control. Doctor has no idea what's going on with the claims, and that's just not okay. You are a part of the billing department. You are the head of the billing department, and you need to be informed.
Assistants As Claim Builders
SPEAKER_00The next role is the dental assistant. And we call the dental assistant the claim builder. A lot of offices completely overlook the dental assistant when we're talking about billing. And I know some of you are probably wondering why I even include assistants in the billing department. And that's a fair question. Most offices don't consider assistance a part of the billing, right? Because in dentistry, there has forever been this line between the front office and the back office. And rightfully so. They are a part of the clinical team. However, billing starts in the back. Most offices don't consider that. Well, I do, and now you should too. Because again, when the billing starts in the back and not at the front, the dental assistant is the one that is responsible for supporting the claim before the claim even is created. And I want you to think about that for a moment because the biller, before the biller touches anything, before the insurance company reviews anything, and before the claim is submitted, the assistant is already contributing to whether that claim will get paid. They need to understand what the x-rays need to look like. They need to understand when an intraoral photo is required. They need to understand when both are required. They need to understand when to stop the doctor and capture the documentation or the intraoral photo. This is very common with buildup. I need a pre-buildup intraoral photo. So this is this is the sequence that I teach my assistants. The doctor is going to excavate the decay and then place the buildup. But before the doctor places the buildup, I need you to stop the doctor and take an intraoral photo so that I have sufficient evidence proving dental necessity that there was less than 50% tooth structure remaining so that we need to place a buildup for retention purposes. Otherwise, that crown's not gonna sit, right? But how do I prove that if all you're giving me is a picture of the buildup already placed? That doesn't prove my case. That helps my case, but that's not the piece of evidence that I need to go to bat in the event the insurance company unreasonably denies my claim. So my assistants need to be educated on what I need as the biller to A, get the claim paid and B, a complaint with sufficient evidence in the event that the insurance company plays the unreasonable denial game. And you know that they like to play that game. So assistants play a huge role in the billing department. They are key players. Everybody is a key player, and we're gonna go through all of these roles, but it's my suggestion that as you're building out your billing department, that you have a billing guide for your assistants. Now, the billing guide is not gonna be comprised of CDT codes. What I recommend is the most common procedures that are billed that require attachments to create a cheat sheet, you know, crowns. And crowns need pre-operative x ray, post op x-ray. So crown prep appointment, here's all the things I need, crown delivery appointment, here's what I need. Any intra-oral photos, any x rays, whatever the biller needs to get those procedures paid. And notice I am not saying on the first pass. Here's a very common misconception that I hear in dentistry that literally makes me want to throw up. I can't stand it when I hear individuals talking about how to get claims paid on the first pass. Friends, we have no control of claims getting paid on the first pass. I know this because I geek out on case studies, I geek out on insurance company audits by the insurance commissioner. I like to see what they are getting fined for. And the most common reason that I see insurance companies getting fined for, based on the research that I've done so far, is insurance companies deliberately denying certain codes on the first pass so that they can retain more dollars in their pockets for that quarter. So you cannot predict that because you put together the most solid package, that the insurance company is going to respect that and go, wow, this is a very well put together package and we need to just pay this. They don't operate like that. They operate from a place of retaining dollars. So it helps when our assistants know what to help us with as billers so that we're not calling patients back into the office because we forgot to get a perio chart. Or worse, we did the perio chart and now we have to redo it because we didn't indicate any bleeding sites. Or worse, the patient left and we forgot to get that, we forgot to get that postoperative x-ray, and now we're not going to get paid because the patient is out of town for the next two weeks. So it is so important for our assistants to really understand what that looks like. Now, I will be putting a link in the show notes to an example of what we use when we train our assistants. It's a cheat sheet, dental assistance cheat sheet, and it has helped offices with onboarding, it has helped with training, and it's just really helped smooth out the billing process because we are no longer frustrated with an assistant having a cone cut on an x-ray. Because cone cuts really do affect our ability to get claims paid, not having the apex, even if it's not a root canal, final x-ray for a root canal, that's a given, right? So if you're an assistant and you're taking an X final x-ray for a root canal and you cut off the apex, that's just plain lazy. But it is also our responsibility in leadership to make sure that they have no excuse to fail. And I find for my assistants, this cheat sheet really helps them. Okay,
Hygienists As Documentation Drivers
SPEAKER_00so moving on from the assistant, we're gonna talk about the hygienist. And just like the assistant, the hygienist has a direct impact on reimbursement. I had a meeting yesterday, and I want to talk about that meeting a little bit because it perfectly illustrates this role. Jen, who many of you have heard on this podcast before, who serves as both a biller/slash hygienist for a couple of our practices, said something that immediately got my attention in the meeting. She said to the office manager, we were meeting with the office manager and the assistant office manager. This is a very big outfit. This practice does about four to five hundred thousand dollars in collections per month. And about 50% of that is insurance. So Jen is the main biller. And she said to the office manager, I love that you guys are using 4346, but I'm not seeing bleeding points documented on the period chart. And without showing that there was bleeding in 30% or more of the mouth, I'm not going to be able to get that paid. That statement says everything. The office was using, the office is using the code, right? So we taught them to go beyond the bloody Profi and document for what you're actually doing. The clinical condition existed, but the documentation was not supporting the claim. And without support, reimbursement then becomes difficult because now the insurance companies they see 4346 and they downgrade it to a Profi. And we have no fighting chance to appeal that downgrade. So this is why I refer to a hygienist as documentation drivers. Their charts tell the story and the documentation supports the diagnosis. Their record keeping justifies the procedures. And if those charts are incomplete, those clinical notes are incomplete, even the most appropriate treatment can be denied. So we have to ask better questions. Are bleeding points documented consistently? Does the periochart accurately reflect the patient's condition? Do we need supporting intraoral photos? Do we need both photos and periocharting? Because, friends, when the clinical documentation and billing strategy are aligned, reimbursement in the hygiene department specifically improves dramatically. Not because we're trying to pad claims. Teaching my offices is how to get paid for the services that they're doing, but not documenting for. And this is why in the hygiene department, there is so much money that is just left on the table. And it's sad because you're doing the work, but you're not getting reimbursed for it. You're not getting credit for it. And I see so many underperforming hygiene departments that lack proper clinical documentation that allows us as billers to get paid, to get your office paid for the services that you're already doing, right? So this is why the hygienist is included in the billing department. And one of the roles that we take into consideration, we got to talk about codifying the interactions with their patients. Do we have patients that have been coming in and receiving bloody profis? When we teach offices to incorporate D4346, the gingival inflammation cleaning, and talk about how it is the bridge between a healthy profi patient and what that looks like. A healthy profi patient is someone who is consistent with their recare. And then you have the inflammation, the gingivitis patient who's not quite perio, but they're also not a candidate for a healthy profi because they have bleeding in 30% or more of their mouth. Well, we have to have a better conversation with our patient, right? And that conversation is what prevents the perioconversion from happening. So we're trying to convert this patient who has been categorized as a healthy profi patient through clinical documentation that should reflect that this patient has gingivitis, not a healthy profi, right? But it's that conversation that we find is the big stop. The hygienist typically doesn't want to tell the patient this bad news that, hey, I know you've been coming in for your free healthy cleaning for the past five years, but we've noticed that the past two to three cleanings, you've had some pretty heavy bleeding during your regular cleaning, and that's not normal. So if that continues, we're gonna have to recommend that you get a different type of cleaning. And it's okay to say in that conversation, I don't know how that's gonna work out with your insurance, but I'm gonna let the girls up front talk to you about that and appropriately transfer that responsibility to the appropriate role within the billing department. But again, we don't think about the hygienist being a part of the billing team, and they really are. They really need to know how to have those perio conversion conversations with the patient so that we can get you reimbursed for. What you're actually doing, right? So, really, really important that we incorporate and have meetings and trainings with our hygienists as it pertains to billing. And sometimes we need to go deep on that in training them on how to present certain procedures and other things that we offer within the practice that are not covered by your insurance. And I'm going to do a side note. I am currently, I'm going to release the results of this. I'm doing a survey right now. And I'm talking to non-dental people, just patients, if you will, the public. And I am asking them how they feel about buying services in a dental practice that are not covered by insurance. And I'm going to come back and give you those survey results and the answers. And it's interesting how these conversations are going. And the reason I'm doing this survey is so that I can incorporate these results into my coaching program that we offer through Fortune. So if you're a client of Fortune, we offer billing services. If you're a client of ours, that includes coaching by me and by our hygiene coaches at no additional charge. And the goal is to help your office improve conversations with patients and all the things. I am so excited to share those results with all of you as well as the intention for all of this research is to incorporate it and provide that research and kind of use it as a case study and proof of the angle we need to take when we are having perioconversion conversations with patients so that they can be more, I don't want to say informed, but I do think the way we explain things to patients definitely affects case acceptance. And case acceptance is going to be reflected in the hygiene department in the period performance percentage, which we like to see at like 40% or greater, meaning at least 40% of the perio that's being diagnosed is being treated. And I can tell you through working with hundreds of offices, the average perio performance percentage is less than 20%. So most offices are treating very little of the perio that is diagnosed for so many reasons that I'm not going to get into here. But again, I hope I have solidified the idea that the hygienist is also a part of the billing team. So the hygienist should be placed on that org chart.
Tracers And Monthly AR Discovery
SPEAKER_00So the next person that I want to talk about, that nobody really identifies as part of the billing department, the role within the billing department is the tracer. And we call our tracers the discovery team. And their job is to pull AR every month, insurance AR every month, and to trace all of the old claims. The tracer does the grunt work, whether you have a tracer, somebody who is going to the insurance portal and determining whether or not that claim actually made it, because you guys know, especially if you're a Dentrix slash Vine user, they're having issues. And what we're finding with our offices that use Dentrix and Vine as the clearinghouse is that Vine is saying that the claim was sent and giving confirmation that the claim was sent. But when we do our monthly AR follow-up, we're finding that a lot of those claims never made it. And this is particularly happening a lot with Delta. Those claims are not making it over to Delta. And so we are now with our Dentrix offices who use Vine as their clearinghouse. We are submitting the claims directly through Delta's portal so that we know that that claim actually made it over to Delta because the amount was so significant when we first discovered this trend. It was like, okay, let's just submit the Delta claims through the Delta portal because we just don't want to chance it. So the tracer is the person who's doing all the grunt work for the biller. And sometimes you have a biller who is doing tracing, but tracing is a role within your billing department. We have metrics that our tracers use so that they stay on track. So let me let me back up a little bit. Our tracers pull insurance AR on the first of every month for the previous month. And then they transfer that insurance AR report. They transfer it, no, not transfer, they convert it to a spreadsheet. The spreadsheet is shared with everyone on the billing team. And the tracer starts with the oldest claims, obviously, and works their way down. Now they do are required to work through 25 to 30 claims per day. And we find that that's doable and it does take a few hours to get through that amount of claims. And if our tracer has been assigned five offices as an example, they'll get through 20 claims for each office every single day. Now I want you to think about that for a second as a role, that's pretty good. Because if you have one individual who is also checking patients in, also answering phones, also, they will probably, if they're if they are wearing the tracer hat, they'll probably get through three to five claims for the day. And it'll feel like no progress is being made. So when you take that role away from the front office person and somebody is able to laser focus on just being a tracer, the AR cleanup goes a lot faster. So the role of a tracer can be worn by an individual who also wears the biller hat, the tracer hat, the follow-up hat. They can wear multiple hats, but when I find the tracer is most effective when they can literally just laser in and zoom in on that one task, which is getting through 20 to 30 claims per day. Now it could be one person who says, I'm gonna wear the tracer hat and only the tracer hat for the first two hours of my day until I hit my goal of 30 claims, and then I'm gonna move on to everything else. That's fine. But we've defined that role. We know who is responsible for the goal. And when we have our meeting, we know who to address, the tracer, right? So I hope that that helps you define that role.
What Great Billers Do Differently
SPEAKER_00Now let's move into what most people think when they hear the words billing department, the biller. And I want to challenge that right away. Most people think the biller's job is to submit claims. And that's probably the smallest part of what a great biller really does. Submitting a claim is the easy part of a biller's job. What separates an average biller from an exceptional biller is everything that happens before and after the claim is submitted. The biller is responsible for execution. The biller is responsible for taking all of the information gathered by the doctor, the assistant, the hygienist, front office, the tracer, and turning it into a check, turning it into reimbursement. That requires critical thinking and it requires pattern recognition, understanding how insurance companies behave. The biller submits the claims, the biller posts the payments, files the appeal when necessary, reviews the EOBs, identifies underpayments, catches missing documentation, notices when the narrative is weak, the biller notices when attachments are missing, notices when a procedure is repeatedly being denied. The biller notices when something in the system is broken. That is why I often refer to the biller as the compliance officer, even though we have a separate compliance role on the org chart. The biller is the last checkpoint before revenue is either collected or lost. And here is something I've learned after owning a dental billing company. One biller can handle far more than most people think. In our environment, one biller can manage approximately three offices collecting between $50,000 and $80,000 per month in insurance reimbursement. But there's an important distinction that assumes focused work. It assumes the biller is not answering the phone, not checking patients in, checking patients out, not being interrupted every three minutes. And because this is where I see offices unintentionally sabotaging productivity. A biller is reviewing an EOB. The phone rings. Now they've now they're helping a patient. Then they return to the EOB. Someone asks a question about treatment plan. Now they switch tasks again. Then a patient arrives. Now they're checking insurance benefits. Now they return to billing. That consistent switch tasking creates what I call cognitive fragmentation. The work gets done, but it's but it gets done slower. Mistakes are increased because we're human. Productivity is going to decrease. And over time that creates the dilusion of results. And that's what we don't want. So when offices ask me, how many people do I need in my billing department? The answer is rarely based solely on production. The better question, friends, is what are we expecting this person to do every single day? Like what we have our roles defined. It's kind of like, you know, you have all of the roles, let's just say that they're on sticky notes, right? On your desk, and you have two bodies, two people, and you're going to assign roles to that person, right? So again, you you can have one person handling multiple roles because when you assign the role, you assign accountability, right? And now the accountability needle is moving because I'm going to say it again. Accountability is what gets the needle to move, right? What are we expecting this person to do every single day? Because if you expect one person to answer phones, schedule patients, verify benefits, check patients in, check patients out, submit claims, post payments, work AR, file appeals, and run reports, you don't have one role. You have six roles assigned to one person. And eventually something is going to get neglected. And it's usually your AR. Usually it's follow-up and usually the activities that generate reimbursement. So we want to be very intentional when we assign multiple roles to one person. Make sure that you know they can handle the expected outcomes so that we can hit our goals, right? Okay,
Payment Posting Is Analytical Work
SPEAKER_00moving on, we have the poster. And I think this role gets underestimated because people assume posting payments is like data entry. I can't tell you, again, you guys know I've done this hundreds and hundreds of times. And when I speak to the person who is posting payments who has no dental background and was just taught, go ahead and just follow the EOB. They don't know how to question, they don't know how to push back, they don't even know what they're really looking at. It's scary to me because this is why 90% or more of your patients' ledgers and accounts are incorrect because the person posting the insurance payment doesn't know how to make proper adjustments, doesn't know to question the insurance company's math because sometimes the math doesn't math, right? So they apply incorrect adjustments or they don't know how to calculate a downgrade properly. They are reviewing the EOB and they're verifying an adjustment based on solely an EOB, right? So our patients end up paying for things that they shouldn't have or end up with credits they shouldn't have because if the payments are posted incorrectly, your reports become very unreliable. And if your reports become unreliable, your decision making becomes unreliable. And this is why I tell offices that posting is not clerical work. Posting is analytical work. Done correctly, it protects revenue. Done poorly, it distorts the patient's balance and the reality of money owed to the practice. So does a poster need billing experience? Yes, 1,000%. If someone is starting in dentistry as a poster, you're doing it wrong. And I'm just gonna stop there and we're gonna move on to the next role. The next
Ager KPIs That Keep AR Clean
SPEAKER_00role is the ager. This role lives in the aging report. The ager focuses specifically on outstanding balances and unresolved claims. If the tracer discovers the issue and the biller executes the solution, the ager is responsible for maintaining momentum until resolution occurs, right? The ager is going to live in 30-day balances, 60-day balances. So it's going to live in all of those balances. This role requires persistence. And honestly, friends, it requires a little bit of stubbornness, if you ask me, because insurance companies are counting on you giving up. They're counting on the office becoming distracted, and they're counting on the balance aging long enough that nobody remembers what happened. I've seen this happen. And your ager prevents that. They keep pressure on the process. And they're going to maintain that visibility and ensure that unresolved claims don't quietly disappear into the aging report. And side note, clean aging reports don't happen by accident. Clean aging reports happen because roles have been defined and we understand what the requirement, what the expectation is of each role. So if the tracer's job is to do the grunt work, what is the ager doing? The ager is making sure that the aging report is consistently being worked on. So in the hierarchy of all of this, the tracer is going to answer to the ager. Does that make sense? So the agers' responsibility is to make sure that the key performance indicators, the KPIs that we use to maintain healthy aging, insurance aging, is that the 90 plus day column doesn't have more than 3% of insurance money owed to the practice. The 60 to 90 day column does not have more than 5% of insurance money owed to the practice. And the 0-30 is performing at 92% or better, meaning that 92% or more of your recent claims are getting paid within 30 days. And notice I'm not saying 100% because that is that is not realistic. Again, nobody gets 100% of their claims paid within 90 days, especially if you are an office that is doing anywhere from $50,000 to $80,000 a month in insurance money. I have yet to see that office. And I'm not saying those unicorns don't exist because I do have people that will reach out to me and say, hey, Erica, all of my claims get paid within 30 days. And then I take a look, and well, yeah, they do because you only submit like six claims per day. I'm talking about higher volume. And I have found through my experience the average dental practice will collect anywhere from 40 to 60,000 per month in insurance money. I'm not saying total collections for the pre for the practice, but I am saying insurance. And then going beyond that, we get into higher volumes. One of the biggest mistakes I see in this role is offices treating aging like a monthly project. And it's not, it's an ongoing responsibility. Every week there should be movement, and every week we should see progress. And we need to have an individual who has this role assigned to them accountable for the weekly progress that we expect to see within this role. Insurance AR has a tendency to compound quickly, and these small challenges quickly become larger challenges because they're aging. And when they're ignored, it just snowballs on us. And that's why this role is so critical.
Compliance Beyond HIPAA Basics
SPEAKER_00Now, the next role is compliance. And when most people hear compliance, they immediately think HIPAA. But compliance extends far beyond HIPAA when we're talking about billing. Compliance is ensuring documentation supports treatment. Coding supports documentation. Narratives are truthful, ensuring state laws are followed, federal regulations are followed, write-offs are applied correctly, diagnosis codes are attached appropriately. Compliance protects the practice, it protects the patient, and most importantly, it protects our doctor's license. And perhaps the most important part of compliance is it protects the integrity of the billing process. I've had people who will say, I always verify my clinical notes when I need to send a claim that requires attachments. And that makes no sense to me because even if it's just a Profi exam and x-rays, you still need to verify that the clinical documentation says Profi exam and x-rays because sometimes it's set we we have the patient on the schedule for Profi exam bite wings, and the bite wings never get taken. But the hygienist used a template and the template says Profi exam bite wings, but then you go to the imaging center and there were no bite wings taken. So we need to correct that claim. And that is the essence of compliance. And that's why I will refer to the biller as our compliance officer, because again, at the end of the interaction is the gosh, for lack of a better word, I guess I'll say regulating, but it's really just verifying that everything that happened in that interaction is documented because without clinical documentation, that interaction did not happen. If I were on trial and had to prove that we got paid legitimately for some x-rays and I had no clinical documentation to back it up, then I am going to be seen as getting my practice paid for services they're not entitled to. And that is unintentional fraud. And I know that that sounds a little extreme, but that's really how it plays out. In the eyes of the law, you should not be placing codes and procedures on a claim form for reimbursement if you didn't do them. And in the eyes of the law, if it wasn't documented, it didn't happen. Even though you know 100% you took those x-rays, doesn't matter. In the eyes of the law, you didn't do them. So compliance is everything. Making sure that we're on the up and up is going to be the compliance officer's job. And so you're going to assign this role to an individual within the billing department.
Manager Visibility Through Metrics
SPEAKER_00Now the last one is the manager of the billing department. The manager is the is responsible for visibility, right? Not activity. There's a difference. Activity tells us what happened, and visibility tells us what it means, right? So they're like the interpreter. The manager is going to review the reports in and interpret and identify trends within the billing department. And this is where the manager creates accountability, right? Determining whether the department is moving towards its goals or away from them. And this is where metrics become very powerful. The data tells the story. Insurance AR tells a story. The write-offs tell a story. If we are properly labeling what we are writing off, we can tell a story, right? What we are appealing tells a story. Collection percentages tell a story. The manager's responsibility is to interpret that story and make informed decisions or deliver to the executive of the company, the owner, that information so that they can make better informed decisions. Without this role, practices become reactive. They make decisions based on emotions and they make decisions based on assumptions. And that's not what we want to do. We don't want to make decisions based on isolated incidents or one-offs. When visibility exists, decision making becomes more strategic. The strategic decisions create predictable outcomes.
From Workarounds To Predictable Outcomes
SPEAKER_00As you're listening to this episode, I want you to think about your own practice, not just the people that work within the practice. I see dentists on TikTok all the time to talk about how they have such a great team. And, you know, that's awesome. But what I find when I get to take a look under the hood is that yes, you have amazing people, amazing humans on your team, but we're not defining roles. And although it looks and appears like we are a high-performing practice, when I run the numbers, that's not the case. It's just an emotional statement based on feeling and not numbers, right? So I'm a big believer that numbers tell the story and emotions dilute it. So I want you to think about the roles you have defined within your billing department or in your practice. Can you identify who owns each of these roles? Can you identify where accountability lives? Can you identify where responsibilities are overlapping? Or what about if the responsibilities don't exist at all? Did your team make up their own workarounds and now it's become a regular feature within your practice, but it's still not necessarily getting you guys to the goals that you want. It's just an impromptu workaround that we created because we were tired of doing X, Y, and Z. So this made everything easier. If that is how your systems have been developed, you don't have systems. You have workarounds. And workarounds are a killer of productivity. This is the purpose of this pillar within our six-part billing dental billing department framework that we use to help structure for a startup or restructure for an existing practice that never really thought that billing was anything much more than a task. I mean, a lot of people just view billing as like, yeah, it's something you do when we have downtime. No, because if you treat it as it is something in downtime, you will have down collections. Collections aren't going to match your production. I want you to think about this as creating clarity because clarity will create that accountability. And accountability creates consistency. And consistency is what ultimately creates predictable billing outcomes. Next week, we're going to move into the workflow engine and discuss these roles, how these roles interact with one another and how work should move through the billing ecosystem. Ownership of each role is important, friends. But ownership without process is still incomplete. So until next Tuesday, I want you to reflect on the roles that you've created and how you've assigned those roles to certain individuals in your discs. I'll see you next Tuesday.
.JPG)