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Trojan Today: “Experience is Not Expertise” by Theresa Sheppard

If you check local “help wanted” listings, you’ll notice most employers are looking for someone with one or more years of “experience” in the positions they want to fill. Over the last thirty-five years of my career in clinical, administrative, and academic dentistry, I have discovered that having “experience” is not enough. This is exceptionally true with the administrative team. Ongoing training is essential.

In a practice, once the patient has had diagnostics, evaluation, and treatment consultation, they are turned over to the admin team for financial arrangements. Statistics show that most declined treatment happens in the financial presentation stage.

The position doing coding and billing has the most financial impact on your practice, and that impact can be profitable or devastating.  

A consistently, well-trained insurance administrator and a financial coordinator are very valuable team members. They can usually work with the dentist to increase monthly production by executing a strategy for appropriately phasing treatment. This will optimize patient care by allowing maximum use of patient benefits and can often reduce out-of-pocket costs to the patient. This can also increase the office’s bottom line by hundreds, or even thousands, of dollars. 

Do you have a protocol for training your insurance administrator and financial coordinator? Were they trained by the person who did the job before them, or are they performing tasks a certain way because that’s how they did it in their last office? Formal education and training can have greater impact on a practice than an investment in lasers, CBT, or Cerec machines. Things change rapidly, so it is crucial to keep training current to provide optimal patient care, remain profitable, and mitigate risk.

The responsibility for proper coding starts with the clinical team. The documentation from the clinicians MUST be accurate for the insurance administrator to code properly. The simplest way to achieve this is to code for what you do. That is such a simple thing, yet often remains incomplete or inaccurate.

EXPERIENCE IS NOT EXPERTISE 

Here are a few examples of things I frequently see:

  • A patient needs a 3-unit bridge. Because only the abutments are prepped, that’s what gets documented, and charged out. The pontic revenue is lost.
  • A tooth needed to be extracted and added to existing partial. Many times, that tooth could have been clasped. Not only do we need a new tooth, but we also need a new clasp. Lost revenue because clasp not billed out, or if it was, the patient was not advised of fee.
  • BW & 2PA taken on a hygiene patient. After exam, DDS needs one more PA. BW get billed out but only 2 PA’s. Lost revenue for PA.

Think about it: 1 PA @ $25 x 3 times a day x 4 days a week x 4 weeks a month = $1200. For some, that may not seem like much, but for others it could be significant. Doctor, what can you do with an extra $1200 a month? 

When billing and coding are done incorrectly, it is most always unintentional, but could be misconstrued as fraud by an insurance company. 

Fraud most often reveals itself in situations such as:

  • Performing a perio maintenance yet bills out a prophy. They do this because it “helps” the patient to be compliant because they have no co-pay.
  • “Helping” a patient who lost insurance at the end of the previous month but couldn’t get in until the first so the patient doesn’t lose the benefit. After all, it is only a day or two, right?
  • Charging out for an acrylic partial when a stayplate was fabricated.
  • Billing a full gold crown when a noble crown was delivered.

When doctors find themselves in trouble, usually there is no intent to commit fraud or provide supervised neglect. Nevertheless, the doctor is responsible.

Let’s look at another example where EXPERIENCE WAS NOT EXPERTISE:

#6-11 Pre-auth was sent for pontic porcelain to high noble & abutment high noble. The plan reassigned the codes and approved for pontic porcelain to base metal & abutment porcelain to base metal. 

When the pre-auth came back, no one noticed the codes were reassigned to a lesser benefit, or even though it was “approved”, the patient was well over the max. Bridge was prepped. No consent form, no financial arrangements. No communication regarding treatment plan change in the chair to an all ceramic bridge. Pre-auth was sent for payment; the insurance paid what remained of the patient’s maximum. The patient was billed the balance of several thousand dollars. Would you want to be the one who answered the phone when the patient called?

The patient filed a grievance with his insurance company and the Dental Board. The dentist was held responsible, ordered to reimburse the insurance company, and the patient owed $0. I’m sure the patient loves the free bridge. 

Proper training would have avoided this and brought the approximately $11,000 revenue to the practice instead of back to the insurance company. In reality, the loss is much higher. The doctor had to absorb chair time, wages, lab fees, and materials, but perhaps the biggest cost was damage to the reputation of the practice

Regardless of how much a patient loves their dentist, they will turn in an instant if the financials are not what they expect. And you better believe that everyone they know on Facebook will hear about it! 

In conclusion, you must invest in team training on coding, documentation, and business systems in order to get paid for the procedures performed. You, your team, and your patients will be happier.

You Can Transform from Experienced Team Members To Experts!

Theresa Sheppard, RDA is a Registered Dental Assistant, speaker, consultant, and author, with experience in all clinical and administrative aspects of the dental practice. 

FMI: Theresa Sheppard Solutions, www.TheresaSheppard.com, 209-222-0750, Theresa@TheresaSheppard.com90 or Info@LCPCoaching.com