Built to Get Paid Series - Bonus Episode - Why Production Doesn't Always Become Collections -

A claim can be created in seconds, but a defensible claim takes verification and that difference can make or break your reimbursement. We start with a tough question: if a dental claim is a legal document, why are so many practices submitting claims before anyone confirms the clinical documentation actually supports what’s being billed? When speed becomes the priority, compliance and cash flow both take the hit.

We zoom in on the insurance reimbursement cycle and redefine where it truly begins: the moment treatment is rendered, not when the claim is submitted. From there, everything depends on the clinical record being complete and accessible, from notes and narratives to X-rays, intraoral photos, and periodontal charts. I explain why clinical documentation is defensive documentation, the record that speaks for the provider during audits, disputes, or fraud allegations, and why billing teams should measure what prevents claims from being created, not just what’s already aging.

Then we break down the claims correction list, a pre-aging visibility tool that tracks completed treatment that cannot enter the reimbursement cycle yet. Unlike insurance A/R, denial, and production reports, it exposes the invisible money sitting in limbo and helps you spot patterns like chronic delayed notes, repeated missing attachments, or workflow handoff gaps. You’ll leave with a simple seven day challenge to document every reason a claim cannot be created and use that data to build predictable billing outcomes.

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Transcript

Why Speed Creates Billing Risk

SPEAKER_00 0:00

Hello, hello. Welcome back to another episode of the Dental Billing Podcast. I'm your host, Erica Aguilar, and I want to welcome you back to another episode in the Built to Get Paid series. We are not going to dive into the fourth pillar, the command center, this week. This week's episode is as a result of all of the questions I received around the claims correction list that we spoke about in last week's episode. If you're just joining us, last week we spoke about workflow engine and we talked about one of the tools that we use, and it's in the toolkit, the claims corrections list. Now, before we get into that, I want to ask you a question. Did you know that a dental claim is a legal document? I'll give you a second to think about that because most people listening are going to say, of course I know, Erica. Of course I know it's a legal document. Great. Then let me ask you a second question. If a dental claim is a legal document, why are so many claims being submitted before anyone verifies the clinical documentation? If that question made you feel uncomfortable, good. Even better if that question rubbed you the wrong way. Because one of the biggest misconceptions in dental billing is that our job is to get the claims out the door as quickly as possible. I really feel like somewhere along the way, speed to getting that claim out became the primary objective to compliance, and compliance became secondary. The problem with that thinking is that the insurance reimbursement cycle does not begin when the claim is created. The insurance reimbursement cycle begins with documentation. A claim is nothing more than a representation of what happened clinically, friends. If the clinical documentation does not exist, then what exactly are you representing to the insurance company? That's the conversation I want to have today. Because after last week's episode on the workflow engine, I received quite a few questions around the claims correction list. And I realized that a lot of people are looking at the reimbursement from the wrong end of the cycle. Most offices are measuring claims after they have already been created and then submitted, and now they're aging. Very few offices are measuring the money that never made it to the reimbursement cycle in the first place. And that's exactly what the claims correction list was designed to do. After last week's episode on the workflow engine, I received quite a few messages about one specific tool inside the dental billing toolkit. And that's the claims corrections, claims correction list. Try and say that 10 times fast. What surprised me wasn't that people had questions about it. I expected that. What surprised me was how many people immediately recognized that this was a completely different way of looking at reimbursement. Most offices are accustomed to reviewing reports

Claims Are Legal Documents

SPEAKER_00 3:35

that tell them what already happened. They review production reports, collection reports, aging, denial. All of those reports are extremely valuable, but they are also retrospective in nature. They tell us about events that have already occurred. The claims correction list, on the other hand, serves a different purpose. It helps us identify what is currently preventing reimbursement from moving forward. Before we talk about the claims correction list, I think it's important that we define what the insurance reimbursement cycle actually looks like because many people hear terms like revenue cycle and reimbursement cycle and use them interchangeably. They are certainly related, but they're not the same thing. Every dental practice has a revenue cycle. Revenue comes into the business, expenses go out, services are provided, and ultimately collections are received. Today I want to zoom in much further and focus specifically on the reimbursement cycle because understanding where reimbursement truly begins is critical to understanding why the claims correction list exists in the first place. Most people think reimbursement begins

Where Reimbursement Actually Begins

SPEAKER_00 5:06

when a claim is created. Friends, it doesn't. The insurance reimbursement cycle begins the moment the treatment is rendered because from that point forward, there's a series of events that need to occur correctly if reimbursement is going to move through the system efficiently, compliantly, and predictably. The clinical documentation must be completed. The clinical documentation needs to support a treatment rendered. Any x-rays, intraoral photos, period charts, supporting documentation, anything necessary to justify reimbursement must be available and accessible. The biller needs to review that information and verify that what is being reported on the claim is supported by the clinical documentation, the clinical record. Only then can the claim be created and submitted to the insurance company. And I just want to point out here that I know a lot of you will submit claims before the clinical documentation is completed because you've given up on the doctor or the hygienist giving you clinical documentation before the end of the day. This is very critical to the claims correction list because on that spreadsheet, you can assign the provider who has not completed that clinical documentation. And you're also going to assign the amount of treatment that's pending to be billed because we are waiting on clinical documentation. This is exactly where I see many offices unintentionally create risk because they become so focused on getting claims out the door that they lose sight of what the claim actually represents. A claim is not a request for payment. A claim is a legal representation of treatment that was provided to a patient. As billers, our responsibility is not simply to create claims and get insurance payments. Our responsibility is to create defensible claims. That distinction matters. A claim can be created in 30 seconds. We all know that. But a defensible claim requires verification. And that brings me to what I believe is one of the most important concepts in today's episode. If there's one thing you take away from this episode, it's going to be this. Clinical documentation speaks for the dentist in the event the dentist is accused of fraud. The clinical notes speak for the dentist when the dentist cannot speak for themselves. Clinical documentation is defensive documentation. If an insurance company audits the claim, the clinical documentation speaks for the provider. If treatment decisions are questioned, the clinical documentation speaks for the provider. If a regulatory agency reviews the record years later, the clinical documentation speaks for the provider. Without that documentation, friends, there's no evidence supporting what was billed. Without that documentation, there's no way to verify that the reimbursement was appropriate. And there's no foundation supporting that claim. This is exactly where the claims correction list enters this conversation.

The Claims Correction List Explained

SPEAKER_00 8:52

The claims correction list was created because I needed a way to identify reimbursement bottlenecks before they were ever becoming aging problems. We've all worked with that doctor who has a week's worth of clinical documentation just sitting there waiting to be created. And we, if you're a compliant biller, you're not sending those claims off. I needed a way to show my doctor how much money was sitting in queue before it's not even put into motion yet. And the claims correction list was exactly that. When most offices review insurance AR, they're looking at claims that have already been created and submitted to an insurance company. Those claims have entered the reimbursement cycle. The aging clock has started. The claim is being processed, reviewed, paid, denied, or delayed. You know how that story goes within the insurance company's system. The claims correction list exists before any of that happens. The claims correction list tracks treatment that has already been completed, but cannot move into the reimbursement cycle because something is preventing the claim from being created. That distinction, friends, is incredibly important. The production has been made and the patient has been treated, and the opportunity, right, for reimbursement exists, yet the claim does not exist because a required component is missing. In most cases, that component is clinical documentation. Billers, we cannot verify what we are placing on a claim and it is supported by the clinical record. If the clinical record does not exist, the treatment has already occurred, but until the documentation is completed, we cannot validate what happened. We can't confirm dental necessity and we can't confidently create that claim. This is why I teach billers that our responsibility is not to just get the claims out the door. Our responsibility is to ensure every claim we create can withstand scrutiny if it is audited, questioned, or challenged. When leadership begins reviewing the claims correction list, they're looking at a category of money that is completely invisible on the insurance AR report. Let's say that your insurance AR report shows $100,000 owed to the practice. Most offices look at that report and conclude that insurance owes the practice $100,000. And technically that's true. What they don't see is the additional treatment that has already been completed but has not entered the reimbursement cycle because claims have not been created. There may be another 30,000, 40, or even 50,000 sitting in the claims correction list waiting for clinical notes or an x-ray or a period chart. That money does not appear on the insurance AR report. That claim does not exist and it has not entered the reimbursement cycle. So the aging clock has not started for that treatment. Yet the production was completed and the reimbursement opportunity is sitting there. The money is essentially stuck at the entrance of the reimbursement cycle. That is why I describe the claims correction list as a pre-aging visibility tool. I call it the big sister to the insurance AR report. It allows us to identify barriers preventing reimbursement from entering the reimbursement cycle before those barriers evolve into larger operational and cash flow issues.

Patterns That Reveal Workflow Breakdowns

SPEAKER_00 13:03

What makes the report so valuable is that it doesn't simply identify dollars. That's one thing I want you to take away from the claims correction list. It identifies patterns. One of the most common patterns we identify is delayed clinical documentation. And before anyone listening feels personally attacked, let me tell you that this is one of the most common bottlenecks we encounter when implementing this framework. A provider may believe that they are staying reasonably current with their notes because they complete them within a few days of treatment. The challenge is that reimbursement doesn't operate on the provider's timeline. Reimbursement operates on workflow. If treatment is completed on Monday and clinical notes are now completed on Thursday, the treatment sits in idle for a claim to be created for three days. If that happens consistently across multiple providers, then we have a ton of treatment throughout the year that is delayed before it even enters the reimbursement cycle. What initially appears to be a documentation habit quickly becomes a cash flow issue. More importantly, it becomes a visibility issue because most practices have no mechanism for measuring the impact of that delay. The claims correction list changes that. Now we can see how much reimbursement is waiting on clinical notes. Now we can identify whether the issue is isolated or systemic. Now we can quantify the impact and have an informed conversation based on data rather than assumptions. The same thing happens with x-rays. Same thing happens with intra-oral photos or period charts. The same thing happens with additional information that should have been captured before the patient ever left. When practices begin using the claims correction list consistently, they stop asking why collections are down and start asking what is preventing reimbursement from moving forward. Those are much better questions. And better questions are going to lead to better decisions. This is one of the reasons I spend so much time focusing on visibility when I work with practices during our implementation accelerator sessions. Could a practice implement the toolkit on their own? Absolutely. 100% capable. That is exactly why we created it. Every template, workflow, report, and system inside the toolkit was designed so that an office could begin implementing these concepts immediately. What I found, however, is that many practices don't struggle with implementation. They struggle with interpretation. They can see the report. During implementation sessions, one of the first things I teach is how to identify patterns inside the claims correction list because the value is rarely found in a single entry. The value is found in repetition. It's really found in recognizing that 20 missing narratives may point to a workflow issue, that 30 incomplete clinical notes may indicate a documentation habit, or that repeated requests for supporting images may reveal a training opportunity with the clinical team. Once management learns how to interpret those patterns, the conversation changes completely. The office stops reacting to problems and starts preventing them. You stop operating from assumptions or those incidents where you scratch your head, and now you're operating from a place where you have data and evidence, and you stop treating billing as a collection of disconnected, fragmented tasks and start managing it as a business within a business. That shift is subtle, but it's transformational because once reimbursement becomes measurable, you can manage it. And once you can better manage it, it becomes more predictable. And that is ultimately what this framework is designed to accomplish. It is not designed to prevent denials because, friends, we have no control over unreasonable denials from insurance companies. There is no magical, magical world where insurance companies suddenly become easy to work with. But the objective here is to create predictable outcomes in the billing department and creating enough visibility throughout the reimbursement cycle so that management can identify bottlenecks, strengthen the systems, improve accountability, and make informed decisions before small problems become cash flow issues. And that is exactly what the claims correction list helps

Your Seven Day Tracking Challenge

SPEAKER_00 18:46

you do. This week, I want you to identify every step that needs to occur between treatment being completed and a claim being submitted. Then identify every reason a claim cannot be created. Not denied, not delayed, cannot be created. Document those reasons for seven days and begin looking for patterns. You may be surprised by what you discover, or you may just see validation in what you already know. If you have been enjoying this series and finding value in these conversations, I would greatly appreciate you taking a moment to leave a review for the podcast. Reviews help us reach more people just like you, and hoping that we can help them strengthen their systems and improve reimbursement outcomes. And if you have not yet downloaded your copy of the dental billing toolkit, I encourage you to do so. The toolkit contains the exact templates, workflows, reports, implementation resources, and accountability systems we've discussed throughout this series, including the claims correction list we covered today. The link is in the show notes. You can also go to dentalbillingdoneright.com and grab your toolkit there. Until next time, keep building systems that create visibility, strengthen accountability, and support predictable billing outcomes. See you in the next episode, friends.