Editor’s note: last month, we looked at insurance-free options. Here we have Teresa Duncan, one of the top insurance authorities in the profession, with some hints and important ideas for those of us who do work with dental insurance.
Insurance management has become significantly more time-consuming than ever before. Concerns shared by most offices center around task management and deciphering patient benefits. It is not just participating offices that struggle—even fee-for-service practices feel the pressure to be accurate with estimates and financial conversations. Experienced insurance coordinators are fine-tuning their systems on a regular basis, but what about the new administrative team members? How will they know if their systems are flawed?
They learn by continually assessing the why of their current systems. Why do some offices send claims only at the end of the day? Why call for full benefits on every patient? Why reconcile checks once a week? Why send statements only once a month? All these examples were regarded as conventional wisdom at one time. Electronic capabilities changed the way we do these and many other tasks. Let’s dive into some concerns I regularly hear from attendees and clients.
Is it True That Secondary Insurance Claims Should Be Printed and Mailed With the Primary Explanation of Benefits (EOB)?
I haven’t mailed a secondary claim in years, maybe even a decade. You can submit the EOB as an attachment to the secondary claim. You will need to scan it so it can be sent digitally. Paper claims are not traceable, which is why I’m not a fan. Electronically submitted claims result in a transaction or tracking number, which is necessary for follow-up questions. Keep in mind that paper claims take longer to be processed. Claims with attachments can take even longer than that. Revenue cycles should be as short as possible; mailing claims increases your payment cycle.
Carrier portals and some clearinghouses can display the EOB. Insurance systems can now include taking screenshots of an online EOB and sending the screenshot to reflect the primary payment. Most carriers will accept this screenshot as long as it provides the same information as a printed EOB.
Do I need to Check Benefits for Every Patient Appointment?
We track down plan benefits so that we can provide our best estimate of the patient’s portion. Every time we get this right, our confidence level grows. It’s a time-intensive task, however. Frustrated team members tell me that they check this for every patient, every appointment. That’s overkill. For his or her first appointment, this makes sense, but not for other appointments in the same benefit year. Plan design doesn’t typically change midyear, so save yourself the time.
Utilize your electronic capabilities as much as possible. It’s possible to check for this information via software, web portals, or faxback services. If benefit checks are overwhelming your office, then it may make sense to outsource this task.
I’m Interviewing Someone who Claims to Know Insurance. How can I Tell if the Candidate is Actually Good With Coding and Claims?
An insurance coordinator from a single-provider location will have a different skill level than one from a multi-location office or DSO. Multiple providers and networks and a wide range of billed codes bring complexities that a solo office will not face. An applicant from a solo setting will quickly pick up on the changes as long as you give him or her time to adjust. Willingness to continue learning is key to this role. Just as clinical materials change and improve, so does insurance management.
You could also quiz him or her on a few basic concepts and experiences:
- How do you calculate payment when a deductible is involved?
- What documentation is needed for scaling and root planing submissions?
- What is a missing tooth clause?
- Which procedure code is the most problematic for you, and why?
- How do you handle a patient who wants us to write off his or her portion?
An experienced coordinator will be able to answer these questions. The most important question is this one: How often do you take CE on dental insurance? If the reply is “I’ve been doing this for 5 (or 10 or 20) years; I know what I’m doing,” you should end the interview and be thankful for the warning sign. The best insurance coordinators I meet (and have trained) know that every year, carriers change policies, networks grow, and the current dental terminology is revised. Secondary insurance and non-covered services are handled very differently than 10 years ago. Standing still in this field is a guarantee for delayed and denied claims.
I am a Dental Assistant. Could I Be an Insurance Coordinator?
A million times, yes! The best coordinators I have trained have had extensive clinical experience. A huge learning curve for new employees is dentistry itself. Our terminology and procedures are not the easiest to learn. The requirements for documentation will make sense to an assistant—you had a front-row seat to those procedures! You will be able to quickly pick out any applicable radiographs and intraoral images. Discussing patient benefits will be easier because you already know what the patient is most likely to be concerned with. You have heard it all before. I would love for all insurance coordinators to spend time in the operatories to learn about procedures and the rationale behind treatment. This is valuable information.
Why Is It More Difficult Now?
An unfortunate combination of dental benefit complexities and workforce weakness has brought us to this point. Let’s tackle the carrier side first. No longer can we assume that dental plans follow traditional designs. Here are a few coverage examples that can take your office by surprise:
- Preventive and diagnostic services are very often subject to deductibles. In the past, these categories were usually exempt.
- Radiographs are often subject to deductibles, but evaluations may not be. This requires your insurance coordinator to adjust the category tables, which can be time-consuming—even for experienced software users.
- Within the oral surgery category, simple extractions can be covered at a higher percentage than surgical extractions. Again, this requires software modifications.
- Timely filing deadlines of 180 days (vs the traditional 365 days) are becoming common. If you are dealing with a difficult claim (multiple appeals) with secondary coverage, you may come up against this barrier. A new employee tasked with cleaning up aging claims will be frustrated by this more restrictive limitation.
Plan designs will continue to change. Medicare Advantage dental plans are bringing new complexities, such as quarterly vs yearly benefit amounts. Every year will bring new plan designs and limitations.
The workforce issue has affected both practices and carriers. It is common to hear of 3-plus-hour phone hold times with carriers. Although carrier portals contain claim and coverage details, we need to speak with a live representative for many reasons. Understaffed carriers and their call centers mean less timely answers for our patients. Dental practices also suffer from understaffing, with the most significant issue being a substantial learning curve regarding the insurance coordinator position. I have lost count of doctors who lamented hiring for the position only to have the applicant quit with comments like “this is not what I expected” or “insurance is too complicated.” My hope is that we can attract more candidates to our industry. This will not happen overnight, unfortunately. The position is a specialized one that requires a fast-thinking and detailed candidate. A person with this personality mix will quickly pick up on the nuances of the job. If you are lucky, your candidate will love challenges!
Effective insurance coordinators are very good at pivoting. We have learned to be flexible in the face of often-changing benefits and new plan designs. Perhaps your interview question should include “Do you like a good puzzle?” A great insurance coordinator will smile and say, “Absolutely!”
ABOUT THE AUTHOR
Ms. Duncan received her master’s degree in healthcare management from Marymount University in Arlington, Va. She has more than 20 years of healthcare experience, and frequently addresses topics such as insurance coding, office manager training, and patient conversations. Her memberships include the National Speakers Association and the National Association of Dental Plans. She is the author of Moving Your Patients to Yes: Easy Insurance Conversations as well as a contributing author to the ADA’s annual CDT Companion Guide. Her podcasts, Nobody Told Me That! and Chew on This!, provide regular coding and management updates. She can be reached at odysseymgmt.com or via email at firstname.lastname@example.org.
Disclosure: Ms. Duncan reports no disclosures.