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
REPLAY: Avoiding Prison with Defensive Documentation with Dr. Roy Shelburne
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A dentist, practice owner, and self-described “billing and documentation geek” sits down with us and tells a story most of dentistry never expects to hear: Dr. Roy Shelburne was convicted and went to prison after years of investigation tied to his Medicaid-heavy practice. The numbers are not the point. The system is. If you think “we didn’t mean to” protects you, this conversation will change how you look at dental billing compliance and clinical documentation.
We dig into the uncomfortable legal reality behind intent to defraud, including “blind disregard,” where repeated errors without a system to find and fix them can be treated as fraud. From there, we get practical fast: what defensive documentation looks like before a claim is ever sent, why diagnosis must come before treatment, and how dentistry is inching toward more diagnosis-driven workflows (think ICD-10, not just CDT codes). Perio examples make it crystal clear: if the record doesn’t state the diagnosis, your SRP and inflammation-based codes are standing on thin ice.
We also talk audit triggers you can prevent today: crown claims with no justification in the chart, radiographs that are not diagnostic, and documentation gaps created when notes get entered later or copied from rigid templates. Dr. Shelburne shares how to delegate documentation safely with flexible templates, how to track non-diagnostic radiographs to improve training, and how to stop “billing to benefit” so your treatment aligns with standard of care. We close with appeal strategies, payer criteria, and the mindset that helps you get paid what you are legitimately owed while lowering risk.
If you want fewer denials, fewer clawbacks, and more peace of mind, listen, share this with your team, and then subscribe and leave a review so more practices build safer systems.
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Welcome And Meet Dr. Shelburne
SPEAKER_01Dr. Roy Shelburne, thank you so much for being on the dental billing podcast. I am so excited to have you here. We spoke a couple weeks ago and we tossed the idea of having you on the podcast and you went on a very long vacation, which where was that too again?
SPEAKER_00I did Norway and the Baltic.
SPEAKER_01That's right.
SPEAKER_00It was wonderful.
SPEAKER_01Yes. So we kind of reconvened a couple months after that. And here we are. And here we are. I'm so excited. For the listeners that have never heard of you, we have a lot of front office team members, new dentists, a lot of people starting their practice. Why don't you introduce yourself and let them know who you are and and and what your mission in dentistry is?
SPEAKER_00Well, thank you, Erica. I appreciate the invitation. Always good to be able to speak with like-minded individuals who are billing, coding, documentation geeks, and I love that about you.
A Dentist’s Fraud Case And Fallout
SPEAKER_00I am a dentist, husband, father, practice owner, now grandfather, and a convicted felon. I went to prison for healthcare fraud, raggeteering, and money laundering. But I bet few of your listeners have heard of CV like that unless they've heard me introduce before. Practiced in the western part of Virginia for 27 years, flew to San Francisco, California to the American Dental Association meeting, and while I was there, I learned that the FBI had come to my office. They battered down my back door and were taking all my records. Was investigated for a period of three years, then indicted, then a year and a half later went to trial, was found guilty of healthcare fraud, racketeering, money laundering, and structuring. The jury is never made aware of the amount. It was a Medicaid issue. Lived in a very small town in the western part of Virginia, and about 90 to 95% of our individuals under 18 had Medicaid. So I had a busy Medicaid practice, felt it was important to take care of those individuals. And they did the investigation over a period of six and a half years. And over the six and a half years, I was paid three and a half million dollars, which is a very active Medicaid practice. And as I said, the jury has never made aware of the amount. They only determine guilt or innocence. The government determines the amount that I got that I wasn't entitled to. And did we make billing errors? We did. The amount that I was paid, $3.5 million, the amount that the government established of the $3.5 million I got that I wasn't entitled to, $17,899.57. That's 0.01% of the amount that I billed. And even though we were able to go over the same six-year, six and a half year period and look over our billing and coding, and we found work that I actually had done, could have billed for, should have billed for, but didn't, to the tune of about $30,000. And that, so that made no difference. So the story is the amount makes no difference. And I guess to segue to one of the things that we talked about in terms of responsibility, even though I didn't directly do the billing myself, somebody did it on my behalf. I'm still held responsible for. And there have been actions in the near past that not only have they named the doctor in the action, but also team members. So everybody has skin in the game, and that's the thing that I want to share that we all have responsibility and we're all equally accountable in the event that there's an action taken. And as I said, in recent actions, I do name team members. So we all have skin in the game. It's all my goal, my passion is to be the last dental professional who goes to prison for things they didn't know or understand. So I share my story, not because I'm proud of it, I'm very ashamed of it, but I want to be the last professional who
What Intent To Defraud Means
SPEAKER_00goes to prison for things they didn't know or understand. One of the things I didn't understand was the definition of intent to defraud. I knew if you submitted a claim for a patient you never saw for a service you never provided, certainly that would be considered fraud. But the legal definition of intent to defraud is much broader. It includes what's called blind disregard, which means if you make similar errors and don't have systems to identify and correct those errors, that is considered blind disregard and intent to defraud. So there's no such thing as an innocent mistake. So we'll be talking a little bit about that today so that, like I said, I share my story not because I'm proud of it, but I want to help others to make sure that they don't make the same errors. That's my story, and I'm sticking to it.
SPEAKER_01And I love that. I I love the topic of, you know, there's no innocent mistakes. And in your bio on your website, you state that there ignorance is not a defense.
SPEAKER_02It is not a defense.
SPEAKER_01I have heard your story in the past, and one of the things that I took away, and this was probably 10 plus years ago when I first heard your story, it was shared on a YouTube channel and it was a video. You have many videos on YouTube, so I do recommend everybody go check out those videos. Dr. Shelburne is powerful. And one of the things that you talked about was your documentation has to be able to defend you when you can't. And you talked about defensive documentation. I have a dental billing company, so I do billing for offices, my team and I do billing for offices all over the country. One of the things that we are very firm on with our clients is no billing without documentation.
Defensive Documentation Starts With Diagnosis
SPEAKER_01I don't care if the treatment is posted to the ledger or to the account. That is not okay to bill that because I don't know, I don't have any clinical documentation to compare what was posted, diagnosed, and all of the things, components that go along with compliance. So could you talk to us a little bit about the elements that are needed for defensive documentation and clinical documentation, what that should look like before you bill it?
SPEAKER_00Oh, absolutely. And when I when I speak, I always ask the makeup of the audience, how many doctors, how many front desks, and I always ask through the course of the lecture is how many of you always get all the information you need as billers to submit a claim and get it paid without delays or request for additional information? And nobody holds up their hand because there's always that dropped ball where they don't have the information that they need. So they have to go fetch the doctor or the assistant or the hygienist to be able to give them that information. And if you want to arm your business people with everything they need to be reimbursed, number one, make sure that you document accordingly. And documentation is not only going to get you paid, it will protect you because it will testify for you loudly and strongly in any action. And it's a way of elevating patient care so that you aren't called on to remember about this patient. It's all there in black and white, so you can move very directly from appointment A to appointment 13 and be able to look back, and there's a story that you can follow. You need to develop that story, but before you treat anything in a patient's mouth, it needs to be preceded by a diagnosis. For example, I see a lot of practices doing active periosystems in their practice. And I almost never see a complete periodontal diagnosis, which contains three variables. It's either mild, moderate, severe, generalized, localized, chronic or acute periodontal disease, or inflammation if it's gingivitis. And I see charting, which would suggest there's periodontal issues, and I see uh X-rays, which would suggest as well, and I see treatment, but no diagnosis prior to you can't treat before diagnosis. And, you know, I'm gonna chase a rabbit here, Eric. We talked about my ADHD, so I'm gonna, this is one of those that I'm gonna do.
SPEAKER_01I'm really holding back right now, just so you know. I'm really trying hard not to cut because I'm like so excited about this topic.
SPEAKER_00If my crystal ball works the way I think it's going to work, we are going to move from dental billing using CDT codes to medical billing completely using ICD codes. And our medical colleagues, before they treat anything and before they're reimbursed, there needs to be a diagnosis prior to. In dentistry, we don't get the diagnosis, it means nothing. We get paid on what we do, which is backwards. You need to diagnose first and then put together a treatment based on the diagnosis, which takes into consideration what we're treating and why we're treating it so that it's paid. So you understand what you're treating. Anybody else who follows up can understand you've diagnosed this, and that's the reason why you're treating it. And it's also moving us so that we're more capable of billing to medical. Okay, you had a question. I'm sorry.
SPEAKER_01We're going to be doing an event together here in a couple months. And I will survey the audience and I always ask the audience, how many of you are using ICD 10 codes? And there will be zero hands that go up, or maybe one or two at the most. I agree with you. There are so many times, particularly with hygiene, when I am billing for SRPs or I see a bloody bid profit documented. And I I'm not a dentist, I'm not a hygienist, but I know enough from the billing standpoint, perhaps that could have been a gingivite, a gingival inflammation cleaning. And so I go and I look for the diagnosis and there is none. There's nothing. So what we documented or what my hygienists document are the bloody bid profies, but particularly recently, I just vented about this in a Facebook group. And it was billing for SRPs and I had no period chart on vial. None. And I don't know how we could have properly diagnosed the patient with SRPs having periodontal disease, generalized chronic. I didn't even know which one it was. So I didn't know which diagnosis code I could use in to submit that claim. That just got me really fired up because I experienced that on a regular basis. And that's why I try and emphasize to my clinical teams that billing really does start in the back from the coding systems to the clinical documentation. And the reality is me as a biller, I'm just packaging it so that it's a clean claim submission.
SPEAKER_00Right.
SPEAKER_01It starts in the back.
SPEAKER_00Well, and to your point, a couple of points. The ADA claim form was updated in 2012 to include what? I see. Diagnosis codes. You have boxes, you can add diagnosis codes. Were it something they would have done had that not been anticipated to be used? No, people don't do things unless they feel like they're going to use them. So, yes, that's indicates. And there are now six states. If you see Medicaid patients, the diagnosis codes do need to accompany the claim. And for example, the 4346, it is scaling in the presence of moderate to severe generalized inflammation. Isn't the moderate to severe and generalized part of that diagnosis piece so that that should be contained within the dial the documentation of that patient so that that biller then is capable of billing that? Because unless that criterion is met in that clinical record, technically it's not billable because what supports the clinical submission,
The Crown Note That Triggers Audits
SPEAKER_00the documentation that's sent to the insurance company. Of course, it's a clinical record. And worst case scenario, let's let's talk about. I'm a storyteller. We'll tell another scenario.
SPEAKER_01I love it.
SPEAKER_00So doctor diagnosed the need for a crown on tooth number 14. The person who's doing the billing opens the clinical record, and lo and behold, there's no justification for the crown there at all. It just indicates that the crown's necessary on tooth number 14. Biller needs to submit that to the insurance either as a pre-D, and we can go there if you want to, or as a claim.
SPEAKER_01I have so much to say there.
SPEAKER_00So the billing person finds the doctor and goes, You've diagnosed the crown on tooth number 14 from Mrs. Smith. Can you tell me what's going on there? As a doctor, you fire it off. Meseofacial cusp was fractured off, the tooth was two-thirds alloy, marginal decay around the tooth. We need a crown to restore contour and function. The person is riding furiously and goes forward and enters all that information with the claim to the insurance carrier, fired off the insurance carrier, paid without any delay because all the information's there. But the person who listened to that scenario from the doctor was not trained or incapable of entering in that clinical record for the patient. So it's gone forever. And for example, the doctor is audited by an insurance company and they pull this particular patient that we've talked about, they're chucked to review. They have a claim for tooth number 14 with all the documentation necessary to support that claim. They open the clinical record and there's nothing there to support it. What happens to that reimbursement? They ask for the money back. And insurance companies in today's world can pull then 15 charts for patients who have had crowns delivered, and they find that 15% of those charts have no documentation to support the need for the crown. The insurance company uses that 15% and goes back over the course of seven years because a statute of limitation on fraud is seven years and asks for 15% back of all the crowns they've paid over that seven-year period. Doctors have written checks back for the insurance company for $350,000 because they have not documented appropriately. So is it important? Yes. Some of them only care about the reimbursement. The documentation is something that goes, ah, you know, that doesn't mean anything. We really don't need to do that. It only matters when it matters. Yes. So that would have saved this doctor had they, had the person who had listened to the information been trained and capable of entering that information in the clinical record, then the doctor would have had the documentation there necessary to support the need for the crown, and all would have been good. However, that simple training and the ability for that person to be able to enter that information was not followed through with.
SPEAKER_01And I know this because we have offices that are still going digital. And they are using that method of just documenting, you know, writing it down, jotting it down. And then they will go when they have time, go enter everything into the computer if it ever gets done.
SPEAKER_00Yeah. Who has who has that much time?
SPEAKER_01Nobody in today's in today's employment landscape in dentistry, they're everybody's short staffed.
SPEAKER_02Absolutely.
SPEAKER_01So we run the risk of missing these key points, these key elements to the process that could have you writing a check for $300,000. And I know I've been a part of those audits with the doctors who call in panic and say, Erica, what do I do? I think I'm gonna have to write this check for $84,000 back to Aetna. And Aetna is my my number one insurance company in my office. And so what they're if I can't write this check, they're just gonna start deducting it from future payments.
SPEAKER_02Yes.
SPEAKER_01So you're gonna pay it back. Either way, I love that point. So I think number one here is make sure that the clinical team knows how to enter the diagnosis, the treatment plan, and all of those things that are important to defensive documentation. Is that what that's saying?
SPEAKER_00Absolutely. The same documentation that is going to get you paid will also protect you in the event of a malpractice claim.
SPEAKER_02Yes.
SPEAKER_00Attorneys are just like everybody else, they look for the low-hanging fruit. And if they have a patient that complains about a doctor's treatments, the first thing that that attorney is going to ask for is a copy of the clinical record for that patient. And I can tell you, being very familiar with attorneys at this point, they will look at the documentation. And if it's bulletproof, if it defends what the doctor did and why they did it or the lack of compliance of the patient, whatever the situation is, they read that. It's all documented, it's in black and white. That claim will never happen. That action will never happen. The attorney's not going to swim upstream. It's too hard. However, if that record leaves wiggle room, if there's not complete documentation, if everything's not covered from A to Z, it leaves an opening that they can put a crowbar and pry the thing wide open. Those do move forward. And thirdly, where I get involved more frequently than I care to is with helping doctors with their documentation CEs. And those generally happen when a patient's made a complaint to the Board of Dentistry. And the cases that I've been involved with, the board has done an evaluation. They asked for everything, a copy of the doctor's clinical record, and they review everything. Doctor's treatment met standard of care, no problem with what they did at all, but there was a problem with the documentation. It did not meet standards. So even though they they provided appropriate care for the patient, and that was the primary complaint, because they did meet standard with their clinical record, that brought action against their license as a result of their uh lack of proper documentation. And I've had to remediate them to meet the standard or meet the requirement that the board has established, and that ding the record. That's always on their their board record. So documentation is going to be so important. And unfortunately, dentists and teens feel like
Delegating Notes With Flexible Templates
SPEAKER_00that's the least important thing in their day.
SPEAKER_01So I have a question for you. What does proper documentation? We have a lot of doctors who have their assistants write their clinical notes. And what they do at the end of the day is just review and sign off if that happens. Um when you have an assistant documenting for you, what are your suggestions? Do you suggest a template? Like what how how do you suggest we document?
SPEAKER_00Yeah. So I absolutely suggest that if you can defer anything that is deferable to a team member, I absolutely do it. Doctors, your highest and best use is providing care for your patient and educating them.
unknownYes.
SPEAKER_00However, hear me, hear me very loudly. Do not ever do that until that team member that you're offloading that to is every bit as qualified and able to put together an adequate clinical record as you are. And you can do that with templates, absolutely. I'm not a big proponent of having soup to nut templates. I am a big proponent of having different areas that need to be completed. And it's flexible because if you pull in, for example, a hygiene record and you pull in this huge block of hygiene record into the clinical record, and you don't have the ability to modify that to reflect exactly what you see with that patient, they all look the same. And that was a suggest that all your patients are the same. And are all our patients all the same? Absolutely not. So if you're able to, for example, the periodontal diagnosis or the genival diagnosis, I encourage you to do templates and add drop-down boxes so that the mild, moderate, severe, you can open that, click on whatever it is, generalize, localize, click, uh chronic or acute, click, and you have that laid out. Yes. And there are options that are available. As far as your restorative, those are easier to do if you use the same protocol with your posterior composites. Pull all that in by all means, because you don't have to rewrite that every single time. But yeah, templates are great, but you need to have them flexible enough so that they are modifiable to very specifically address that patient's conditions and diagnosis as they present.
unknownYes.
SPEAKER_00And there again, the team member needs to be able to do that. And the team member also needs to be able to listen and notate. For example, doctor walks in, sits down with the patient, and says, Miss Patient, I'm going to go ahead and do an oral cancer screening. And I can guarantee you that 99.9% of all dentists do that routinely with their evaluations. However, I can also tell you that probably 90% of them never tell the patient what they're doing. So the patient, you sit down and go, I'm going to do an oral cancer screening. The patient never heard this before. You've done it, but they didn't know what you were doing. And they're going, oh wow, this not isn't just a checkup. Getting oral cancer screening as well. So that is going to add value to it, and your team member can listen. Doctor conducted an oral cancer screening. And as the doctor looks, he can, or he or she can go, there's this little red area on the roof of your mouth here. Can you tell me, have you ever noticed that? And the patient can say, hmm, yeah, I think I burned that the other night on PC. Pizza. Doctor can say, well, it looks like it would be consistent with a pizza burn. However, if you would take a look at that, I'm going to give you a mirror. This is what it looks like today. If in seven to ten days it's not gone, then please go ahead and give us a call back. We're going to need to take another look and maybe go a little bit deeper. Team members listening to all that, doctor uh conducted oral cancer screening, noted an area, wherever that area is, instructed the patient. Patient indicated that it they remember having a pizza burn in the area. Doctor indicated that it could be a pizza burn, but the patient is to call back in seven to ten days and let them know what the condition is at that point. So all that's being listened to. The doctor doesn't have to say anything to the team member. The team member's train to listen. Same thing with the TMJ evaluation. Patient opens and closes, Mrs. Smith. I can tell there's a little clicking and popping on the right-hand side. Have you noticed that? Mrs. Smith says, Yeah, I have noticed that. Does it ever hurt? No, no, it's I've had it for years. It's no big deal. So the person listening. So is there a learning curve? A little bit, but anybody can listen. If you hear that, they understand it. Need to capture this in the clinical record. Having that all determined, the patient or the team member knows the responsibility, what they should be listening for and noting in that clinical record, then it becomes organic. At the end of the day, the doctor can review and sign that. And one of the things that I don't see very often is the doctor signing the hygiene record. Hygienists can only practice independently now in three states. And those hygienists need to have the certificate to be able to do that. Otherwise, they cannot diagnose. So anything that's noted there that they is their impression. Well, we talked earlier about everything needs to be diagnosed before treated. That's where the periodontal diagnosis comes from. The hygienist can make a note of their impressions and what their thoughts it might be for the doctor to review and then put their stamp of approval on. So the doctor needs to review and sign those as well, unless that hygienist practices in one of those states so that they can practice independently without the doctor.
SPEAKER_01So let me ask you as an example, say we have a patient that's coming in for a Pro Fee, and they're in the chair scheduled for the Pro FI, and the hygienist realizes this is a gingivitis cleaning. This is not a profi.
SPEAKER_02Correct.
SPEAKER_01The suggestion there would be then go get the doctor, have the doctor review and diagnose, or what would your suggestion be in that case?
SPEAKER_00Yeah, in if that were the case, I would well, what makes it more convenient would be in an air practice, anytime the hygienist has taken the necessary radiographs, done the next necessary screenings, then the doctor's called. So there is a buffer in there. Yes. So that the hygienist is going to have some time to maybe conduct some other do the periodontal probing, if that's the case. So there again, there's need to be awarded, but the doctor has to direct any type of treatment. And to be honest with you, simple
Radiographs Standard Of Care And Retakes
SPEAKER_00thing is a pro fee. X-rays. The doctor has to order the need for radiographs based on number one, medical necessity. Not that the insurance is going to pay for it. I do audits.
SPEAKER_01Wow. So often, billing for benefit. That's a whole other topic that you and I went off on our most recent conversation, friends. We talked about how we see offices billing for the benefit, not for standard of care. And for what you actually do.
SPEAKER_00It drives me crazy. You will never meet standard of care billing for only what the insurance will allow. So Chase this rabbit very, very shortly, x-rays are taken only because they're medically necessary, not because the insurance is going to pay for it. They need to meet standard of care. If you're billing for a radiograph that is cone cut, that is overlapped, that would not pass a proficiency in dental school, hygiene school, assisting school, you are billing for a worthless service. You've submitted a claim. It's a fraudulent claim because the x-ray is worthless. And the third thing preach, preach, preach, and the third thing that needs to be part of the clinical record regarding radiographs is that the doctor read them. Because if it doesn't notate that the doctor read them, then it didn't happen. So you have x-rays that are taken, and according to your clinical record, they're just out there in space somewhere and never having been read. So although we assume that the doctor read them, you can't assume anything that's not in the clinical record. So yeah, there's so many different ways we can go from there, right?
SPEAKER_01Oh my gosh. I I I I in the clinical training that I have with assistants, because they are the ones gathering the attachments that we need in order to get paid, you know, to package a proper claim of claims. So we do spend some time with the assistants. And I talk about this with my friends, you guys, you guys know I've talked about this before. Cone cut, elongation, foreshortened, half the x-ray missing, you know, it we have to retake those x-rays. So if you we're digital. You see it instantly.
SPEAKER_02Yes.
SPEAKER_01So that it meets standards.
SPEAKER_02Right.
SPEAKER_01And we don't from a as a biller, I'm gonna speak billing language, but as a biller, I don't want to give the insurance company an excuse to deny or delay. And when we submit those x-rays, we do give them a reason to.
SPEAKER_00And I'm gonna be I'm gonna expand that even further, Erica.
SPEAKER_01Please.
SPEAKER_00You could also give the insurance company an excuse to audit. Because if if they see a cone-cut radiograph that was submitted to them as if it were standard of care and readable to justify the need for that, I had an office that did that, did just that. The X-ray was not good. The person who reviewed that looked at it and went, I wonder if they think this is standard of care. If we do an audit of this practice through a radiograph, so I wonder what we're gonna find. And they did the audit and they found that 30% of the radiographs that were taken in bill for did not meet the standard of care, were not diagnostic, and they used the extrapolation formula I talked about. They asked for 30% back of all the radiographs they'd paid for over the course of that seven-year period. And that was $112,000 a doctor wrote a check for. So I encourage the practices, and I'm never about punishing anybody. I'm all about identifying areas for improvement. In your practice, you should have a code that you use that is not an ADA code that's submitted the insurance, but it's a non-diagnostic radiograph, so that anytime those are fired, you make a notation that that's fired and that the non-diagon diagnostic films. So once a month, once every six months, run a report and per assistant or per hygienist and just calculate their accuracy. So if you have, if you have one that is 90% accurate, only 10% retakes, and you have one that is 60% accurate, 40% retakes, that's an opportunity for that person to learn and grow. You get the one at 90% to do a little learn, lunch and learn with the individual who is having, who's struggling. Because in most instances, say patient comes in, you're taking a PA, first PA's taken, and it's not great, and the assistant looks at this is not gonna work and takes the second one, and this probably doesn't happen with any of your people who listen to your podcast because they're excellent in what they do, but the second one's worse than the first.
SPEAKER_02Yeah.
SPEAKER_00Third one's taken, it's perfect. And the doctor probably never is made aware of the two that don't meet standard, but who does know?
unknownYeah.
SPEAKER_00The patient. So they're thinking, oh my goodness, they have to take so many to get a good one. And you know, your your podcast people may not, I'm sure this doesn't happen with them either, but they have patients that refuse radiographs.
SPEAKER_02Yes.
SPEAKER_00That happens sometimes? Oh my gosh. Two reasons. One, they don't want to pay for them, and two, they don't want the exposure. And if you have patients who don't want to have a full mouth series taken because they're afraid of all the exposure, if they've had a couple of PAs and it's taken three or four times to take those films, and now you're gonna get 16 to 18 and multiply that by three because it's gonna take you three times to be able to get all those, they're going, that's an awful lot of exposure. That might be one of the reasons why they're thinking, I don't want to be exposed to that many films. Because, you know, so there again, it's a way of tracing that and bringing every body up. You've got one person here at 90%, another person at 60%. You want all of them at 95 to 100%. Well, you can't be at 100%, you can't be perfect because patients are a little bit difficult sometimes to get those films off.
SPEAKER_01Oh, yes.
SPEAKER_00But like I said, it's it's the systems like that to implement in your practice to make sure that you get what you expect, not what you accept. And that happens in all dental practices and families, your children. You don't you don't get what you expect, you get what you accept. Yeah. So if the level's here, you've established your your level for your documentation. Everybody needs to meet the standard, and you don't accept that, then you tend to start coming off from what your expectations are. So there again, to have that system for documentation or any system in your practice, make sure you're clear on your expectations. People are made aware of those expectations and they understand the repercussions if they're not able to meet those standards.
SPEAKER_01Yes,
Stop Billing To Benefit
SPEAKER_01absolutely. And I think kind of jumping into a different topic because this is one of my favorite topics, especially when I'm talking to a live audience, I love to see the reactions and the aha moments when we talk about billing to benefit, not to standard of care or not for what for what you actually did.
SPEAKER_02Right.
SPEAKER_01A perfect example of that is when we have a patient on a periomaintenance regimen and the they bill profi one visit, periomaintenance another. And when you ask them why they do that, and they say, well, because on the off visit, they will only pay for a profit. And so I see your face. We're just kind of like, you don't don't bill for the benefit, bill for what you actually do. What are some other examples that you see offices billing for benefit? Not I had a a list in my but I would love to hear your oh goodness.
SPEAKER_00Um radiographs is number one, evaluations, oh, profies, periodontal maintenance. Oh goodness. Crowns, I mean, you know crowns, core buildups, restorations, you know, you name it. It's kind of like you we're gonna do it this way because this is what the insurance is gonna pay for. Yeah. It's like that's not even right. And you know, a lot of them get all twisted because the insurance company has the least expensive alternative benefit.
SPEAKER_02Yes, the leak.
SPEAKER_00And yeah, exactly. So, you know, there again, there are such things as optional services, and most insurance companies are aware of it, allow you to do that. The insurance company cannot dictate to you, for example, the person comes in, they're missing tooth number 19, and the patient has the least expensive alternative benefit clause in their insurance, and the insurance and the patient wants an implant and crown. So the insurance says, all I'm gonna pay for is the partial, but if the patient wants to have the implant and crown, that in most cases is considered a optional service by the insurance carrier, and you can balance bill the difference between those. And and most people don't know that. And you know, it's they they think, well, you know, I can't afford to do that because they're only gonna pay this. You know, it's it's not a trick, it's something the insurance company is aware of, and they cannot get between you and the patient when there's decision, care decisions being made. Yeah, they have a benefit, they're gonna pay this, it's gonna limit to that. But if the patient wants an upgrade to something different, then by all means you can do that. That's the patient's choice. But yeah, you know, there are all kinds of things like that. People feel like they're limited and they are billing per benefit. Well, I guess we'll just have to give you a partial. No.
SPEAKER_01No, please don't. Yes. Alternative benefits is exactly what I what I talk about when I'm making newer billers aware that we don't balance bill the patient to the benefit. You can balance bill the patient to the treatment that we actually did, or you know, for that matter, we can doctors can do what they feel is standard of care for the patient, but yeah, it's it's that doesn't matter. You know, the insurance benefit doesn't matter. That's just what they're gonna pay for.
SPEAKER_00Exactly. Exactly. Preach on. Yes, the insurance company cannot get between the doctor-patient relationship and the recommendation with that treatment plan that's appropriate for the patient. Insurance can only say this is what we're gonna pay for. They cannot say this is all we're all you can get for this. It's no, it just drives me crazy. It's like, don't do that. Patients deserve better.
SPEAKER_01Exactly. And and I think it's just a matter of a lot of our front office team members just not knowing what they don't know. And that's why I was so excited to have you here today because we're exposing them to things that I don't think a lot of times they get that too, they get that exposure for. So can you talk to us about what you
Getting Claims Paid With Appeals
SPEAKER_01do when you work with an office? What is it that you're looking for? What are you doing when you're helping your clients?
SPEAKER_00So ultimately, I want to help them maximize legitimate reimbursement, reduce the risk. I want to keep them out of harm's way and get paid for everything they're entitled to. And I'll help them squeeze every penny out of that insurance company that they're entitled to, no more no less.
SPEAKER_02Yes.
SPEAKER_00So can you squeeze blood out of a tournament uh tournament? Yes, you can. You know, you teach them about the magic words that go along with the billing that, you know, I jokingly ask individuals when they call now, do they talk to individuals following up on insurance claim? And it's obvious that English is not their first language. Yes. And be it good, bad, or indifferent, many times those individuals don't know a lot about dentistry either.
SPEAKER_02Yes.
SPEAKER_00And they're given a list of magic words that help to justify the reimbursement. And if your supporting information does contain those magic words, I give them a list of magic words. I make sure that when they have denials or delays to make sure that they track that, understand what the insurance is looking for, and give the insurance everything and more that they need to adjudicate that.
SPEAKER_01You can never send too much information.
SPEAKER_00No. No. Well, you can. Sometimes I've seen during appeals, doctors will feel it's important to question the credential and intelligence of the person who are reviewing the claims. That's probably unnecessary to send the claims.
unknownOh wow.
SPEAKER_00So yeah, I I actually I go to the meeting, it's the AADC, the American Association of Dental Consultants. Yeah. And those are the consultants who work for the insurance companies. They are dentists, and that kind of gets behind the curtain. And I talk to them a lot about what the concerns are to make sure that I I know what they're looking at, the things that they feel that we're doing in dentistry to abuse the system. But yeah, don't take any pot shots at the person who is reviewing your claims, that's not a good idea. And actually. Yeah. Insurance companies actually keep a dossier on practices too, which is something that I I didn't know before doing this several years ago. If you're that practice who are dogged about making sure that you get paid, and if it's borderline to push, push, push, they will more than likely, if it's borderline, it's like this one's 50-50, they'll give you benefit of the doubt and pay it because they don't want to deal with the follow-up that is always forthcoming from that practice. So be that practice. If you have grounds to believe that that claim should be paid, by all means, don't give up. And honestly, if it is denied on the first submission because of medical necessity, if you do file an appeal, a different dentist reviews it. And I asked this question when I'm lecturing if you gave the same clinical records for one patient to five different doctors, how many different distinct treatment plans would be generated? And everybody goes five. And I said, No, probably seven or eight because a couple of you couldn't figure out one, you generate two or three. Yes. Dentists don't agree. So there again, the people who review your claims they probably don't agree either. So don't give up. Send it to one, they'll say, No, I don't think you should do that. Another one will look at it and go, Yeah, I think I would.
SPEAKER_01Offices that appeal tend to get less denials, but also we don't want to be that office that is, I don't know, bully-ish towards the insurance company and the person, because we are dealing with human beings and we want to be cordial and we want to ask for maybe a reconsideration, providing additional information if we can. What other suggestions do you have about uh successful appeal strategies?
SPEAKER_00So sure. I would I would have that conversation with the parietal relations area. So if you're getting consistent denials on a particular service that you're providing, have that conversation. You know, I I'm I'm one of your pro providers. We're getting fairly consistent denials on our crowns. Can you tell me what criterion you use to justify the need for the crown and listen and give them the information that they're asking for? You know, they can't pay for something that they not supported in a way that would justify under their criterion of necessity.
unknownYes.
SPEAKER_00And sometimes you can go online and that information is online as far as what they feel is justification for the need for a crown, and follow those criterion and make sure the clinical record establishes those conditions and situations with that tooth that would justify the need for the crown. You know, it's it it some people say, well, that's playing the game. And I said, Well, it's not playing the game. It's just give them what they need to be able to process. You know, it's it they have criterion that's established. And to be honest with you, if it doesn't meet the criterion and they go ahead and pay that claim, they have committed insurance fraud. They've paid for something that should not be paid for. So they have to maintain a certain criterion established in their plan. Otherwise, they're distributing money inappropriately and probably taking advantage of the company who is providing the coverage for that patient.
SPEAKER_01Exactly. And and ultimately, we want our billing processes, we want to fight to get claims paid for our patients so that they can receive the care that they need because they are paying premiums their coverage. So we want to make sure that we are maximizing on insurance reimbursement as a patient-centric service so that we are A, getting every penny owed to the practice, but also that that translates to the patient receiving the proper care and benefit for continuing on.
SPEAKER_00It's kind of like, okay, we're being a pain to this employer, and more than likely when they go to renew this contract, they're probably going to look for somebody else. So maybe we need to take that into consideration when we deny all these claims. So that that's one of my last ditch efforts suggestions to take it to the HR department if it's one of those. If you're that person who is buying the insurance coverage yourself, go to the person who sold it to the insurance agent and say, you know, I've paid for this and they aren't paying for this crown that I should be covered under this. Could you, and then your agent can take action as well. You know, it it follow the money in the insurance company if you get their attention that way. They don't want to lose those contracts. They don't want to lose that that revenue from the employer or from that insurance agent. So be aware of that as well. You can use that as a little bit of leverage as well.
SPEAKER_01Well, I think you and I can, I always say this every time we're we're ending a long conversation about this topic. I always say we could go on and on and on about all of this stuff because we both geek out about uh compliance and billing and maximizing on insurance reimbursement. We are going to be talking about this at our upcoming event in Chantilly, Virginia on November 3rd. I'm really excited about that. That's gonna be a lot of fun. Before we close out, Dr. Shelburn, if there was one piece of advice that you could give in general, what would that advice be?
SPEAKER_00The three things that would be most important to
Documentation Times Three And Closing
SPEAKER_00maximizing legitimate reimbursement, to protect and defend your practice, and to help you sleep well at night, the three things are documentation, documentation, documentation. So even though you think it's the least sexy and enjoyable part of your practice, it will ultimately bring so many rewards and peace of mind that do it, just do it. It's it's it's difficult to get the system down, but once it's in place, it is easy. It and much easier than trying to do a piecemeal if you don't have a system together.
SPEAKER_01I love that. I and it is, you're right, it is not the sexiest part of the day or but it is one of the most impactful. And I love that you said if you want to sleep at night, documentation. So I I agree with that. And with that being said, I want to thank you for being on the podcast. And I look forward to our future conversations about everything related to billing.
SPEAKER_00Well, Erica, thank you. Looking forward to November. It's gonna be great. Thank you for the invitation. If anybody has any questions, if they want to reach out, that's great too. You'll share my contact information.
SPEAKER_01I am going to put your information in the show notes. So if anybody has any uh questions for Dr. Shelburne, he does answer his phone, his cell phone. And and that's a funny story. I was so surprised and shocked when I called the number on his website and he picked up and said hello. He actually picks up his phone. So reach out to him if you have any questions. There's no excuse to not understand what proper documentation looks like, and you have the ultimate resource to reach out to. So with that being said, I will see you soon and talk to you later. Okay, my friends, that's gonna wrap up today's episode on the dental billing podcast. I can't wait until the next episode, and I hope that you join me. Until then, take care.
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