Unlocking the Secrets of Dental Insurance and Billing - Part 1 of 2

Hey, dental associates and new practice owners. Welcome to the Associates on Fire podcast powered by Practice cfo. This is the podcast that teaches you what you never learned in dental school, the financial side of dentistry. We cover topics from planning for ownership, buying a practice, to student loans, taxes, and all things financial for the hungry to learn Dental Associate. So let's light it up.

Welcome back everyone to the Associates on Fire podcast. My, my name is Drew Phillips and I will be the host of today's episode. For those who haven't had a chance to check out our Associates on Fire program yet, I'm a CPA and CFO advisor at Practice CFO and one of the instructors in our Associates on Fire program. Be sure to check us out at www.ass Associatesonfire.com. today we have the wizard of dental insurance and everything that is dental billing on the show, Mr. Ben Tanay. I learned about Ben by sheer accident really when I was trying to explore what non cover services were and how a dental practice would go about administering it. And he had this, I mean, completely well thought out podcast that was available for free on the Internet. I got to know his services a little bit more. I had a couple of clients that, that worked with him and had such a wonderful experience and fast forward, you know, about two years later and I think that I've had about 10 to 12, maybe upwards of 15 dental clients that have, that have worked with Ben in his insurance and billing consulting and has just have such a great experience and such a fruitful impact after the, after the fact. So without any further ado, I'd like to introduce Mr. Ben Tunay.

Thank you, Drew. It's great to finally meet you over the Internet. I guess that's the formal way of meeting during this pandemic, right? Over. Over a video conference podcast. Absolutely.

Absolutely.

Awesome. Well, thanks for inviting me on your show.

Yeah, no, thank you. And, and today, you know, we'd like to get as, as deep as we can in some of the, the mystics and, and sort of mysteries of the insurance and billing world to give our listeners a better idea of hopefully things that they aren't even aware of. Right. And Ben. And we'll leave Ben's contact information both on the website and at the end of the podcast for anybody that wants to reach out to him after the show. You're more than welcome to do that. He's like I said, just, he's a great provider all around, but without, with that being said. So Ben, how did you find your way into the dental world? Just in the, you know, to begin with, and then obviously into the insurance space as well.

That's a good question. It's kind of like how you and I connected. It was through sheer luck.

I was actually in the fundraising part of the finance industry back in 2000, well, the mid 2000s, 2007. A friend of mine who worked for a DSO, his primary role was to recruit dentists he recommended to the CFO at the time, excuse me, CEO at the time, that they probably ought to look at retaining somebody like me to come and help correct and deal with all the insurance related problems.

Interestingly, my friend convinced me to go out to Arizona to meet with the CFO CEO. Excuse me, I say CFO because I'm talking to the master CFO right now. So I met with Dale, the CEO of this group and within 10 minutes he gave me a job offer and said, hey, we'd love for you to come and serve as an executive to clean up all of our insurance processes. And I took the job. What they were offering was a pretty lucrative contract, but I was more interested in the challenge. They said, hey, nobody's ever been able to negotiate our payer contracts. We have guys that have been in dentistry for 40 years and still there's been no progress. And that kind of hooked me. Okay, well I'm going to become, I'm going to come in, I'm going to be the first to do it for you. And I did. It really wasn't that hard. You know, I looked at all the different angles of how the employers contract with the insurance companies. And the insurance companies were saying, hey, we negotiated a great deal for you and your employees to come and see this group of in network dentists. And that kind of opened the door for me to go to each insurance company and say, hey, you're saying that you negotiated a rate, but yet when I look at the contract, the rates aren't negotiated. So we need to start this all over again. That's really how I stumbled upon this whole concept of insurance possibilities, because it didn't stop there. You and I met on the topic of non covered services. A lot of dentists don't do veneers as an example because the PPO allowances are so low. But they fail to realize that there's a non covered service components of veneers, you know, the cosmetic component that the patients can pay for. If a patient wants veneers, you shouldn't be limited to the in network allowances, especially in situations where it's not even covered. You know, veneers aren't covered. And then you have a California state law that says if it's not covered you get to bill your full fee anyway. So back in 2007, I was exploring all kinds of possibilities as it pertained to insurance. You know, what is allowed, how to negotiate what's not allowed from a billing perspective or contractual perspective. And the key thing Drew, that I realized is that there were no businesses in dentistry that assisted dental practices in negotiating fees and providing coaching on the level of what you would typically retain an attorney for, which is, hey, which how do I do a non covered, how do I bill for a cosmetic non covered service case? You know, and so I just decided to start a business around those services.

That's, that's phenomenal. And just to sort of back up and summarize just, just a bit here, I think most of our listeners are probably really well aware of the insurance consulting piece that helps with insurance fee renegotiations. You know, within the first, I believe year and a half been, correct me if I'm wrong, I think in the first 18 months of a new insurance contract you can't do any renegotiations. But after that, you know, it's, you're, it's open for, for renegotiation purposes. And there's a lot of, a lot of companies out there that, that help with that service and something that's probably pretty familiar to our listeners to begin with. And, and if that was the only thing that I knew Ben was, was strong at, maybe I would have never even met him to begin with. But you know, one of the things I really love about Ben's company is that he has this consulting aspect of element to it which you know, as he briefly mentioned on non cover services being one of those components within the consulting realm that he helps with. And so he takes it one step further and he sort of unlocks these Trevor treasure troves of, of billing abilities that you would have to come through legal jargon for, for quite some time and be pretty sophisticated I would imagine to, to uncover some of these, these intricacies. So I kind of want to focus our, our time today with Ben on, on the ladder, which is the consulting piece and some of the nuances that not only his team could potentially help you with, but areas that you may have overlooked and that we could unlock some, some value there since he's already brought up non covered services and that is a typical hot topic for any new or existing practice owner. Let's, let's start there Ben, and just sort of briefly Go over maybe the rules around network non covered service charges, what they are just in general and how you're helping practice owners implement that for themselves.

Absolutely. So non covered services by way of definition are procedures that are never covered by an insurance plan. Meaning, you know, like a good example is a D0180, a perio exam, you know, that's covered by the insurance plan. But if you submit a D0180 and that particular code benefit has been used because it might share the same frequency as a new patient exam, D0150. But had the D0150 not been previously built, insurance D0180 would have been covered. So by way of definition D0180 is not a non covered benefit. A non covered benefit or Service is if DE 0180 is never covered under any circumstance. A good example of that are.

We talked about veneers. Veneers is a non covered service. With most dental plans, build ups are sometimes never covered by the plan.

Materials are never covered. For instance, a lot of practices they like if you're doing a higher end cosmetic case and the lab unit alone is 5, $600 and it's a full on cosmetic case.

The insurance plan covers the functional and fitting components of that dental work. They do not cover the extensive cosmetic nature of that work. And that's more of an extreme example if you bore that down to day to day dentistry. Every Emax crown, every Zirconia crown has a non covered service component to it, which are the materials. So the materials in essence. Now this is in accordance with the American Dental Association. They recommend in their coding guidelines that we submit like on a crown non covered service cosmetic component that we submit. 2999. The problem though, so 2999 goes with if it's an Emax crown. 2740. Right. The crown code for all ceramics. The issue that I have with that is that when you submit 2999 and you describe it as a cosmetic material or cosmetic properties, the insurance plan 100% of the time will say well that's already included in 2740. So you cannot bill this. They call it a. They'll disallow you from billing the patient that fee. That's listed under 2999. Now this is only applicable if you're an in network participating provider. So because of that.

Several years ago, it's more than 12 years ago, Trey, I had a law firm in Tempe, Arizona on retainer and I just asked them questions when it comes to not submitting Claims insurance for certain procedures. Can you do that? They put me in touch with a law firm out of Hollywood and this law firm said absolutely yes, you can have the patient sign an insurance waiver, either a partial insurance waiver, which means, you know, that that insurance waiver is covering treatment that the plan may not cover or does cover, but you know, you've got the patient to agree to pay for those things out of their own pocket, or a full insurance waiver, which is you're waiving every single item on the claim form that is being billed to the patient directly, not to the patient's insurance. And they said that you can do this under the protection of what's called the HITECH act, if you're interested in googling that. It's H I T E C H. It was passed by Congress in 2009, and essentially a short version of that law states that if a patient agrees to an insurance waiver under the HITECH act, under no circumstance can the doctor's office ever disclose that treatment to the patient's insurance. The patient can go and disclose that treatment if they want, but the doctor's office can never have a conversation with anybody, especially the patient's insurance, about that treatment. So in my mind, I'm thinking, well, this is the solution then. This law firm is saying they represent actors is the reason why I was connected with them. Oftentimes the actors insurance plan only covers $1,500 anyway, and it has a list of restrictions on what the dentist can and cannot do. So this law firm has their clients, they present the dentist with an insurance where you're saying, we have insurance, yes, but we will pay for this entire case, you know, this $80,000 case out of pocket today because we need these actors to be smile ready for camera next week. So here's 80 grand and you don't have to worry about submitting it to insurance because of the high tech act. Well, that, you know, that alone, this conversation with this law firm out in Hollywood, it really opened a can of worms in the sense of there's so many different components to dentistry that we either do for free or we just don't do at all, you know, because the dentists are like, I'm not going to do those veneers for $400 a unit. You know, it's. My lab fee is $300 or whatever it may be, you know. So in essence, my introduction or at least discovery of this whole entrance waiver opportunity under the HITECH act is designed to let the patients and the dentists do the work that they want to do, but allow the patients to receive quality dentistry that their insurance plan doesn't want to pay for. And the patients can freely pay for those things out of their own pocket. Now, here's the other thing, Drew. The reason why I mentioned that part, giving the patients the liberty to pay for things out of their own pocket is because that language is already written in the employer contract or if it's an individual plan where you're obtaining insurance directly from a dental. Dental, an insurance provider. The contract language states that if you as the patient or the enrollee choose to obtain a higher value procedure or higher cost procedure, you can do that if you want, but you're going to pay for the difference in cost at your own expense, which means we will pay our percentage against the negotiated allowance that we have with the in network doctor. Anything above that, that's your responsibility. So not only is this supported by federal law to, you know, number one, you can choose to have the patient sign an insurance waiver, but secondly, the insurance plans also agree that if a patient wants to pay for something more like they want gold, you know, if they want diamond studs in their crown, you can get that, but you're just going to have to pay for it on your own. But here's the problem, Drew. If I put gold studs on number nine.

You know, if a dentist seats, seats a crown with a gold stud on number nine and.

You submit 2,999 and the fee there states that the patient has to pay five grand for that gold stud, the insurance plan is going to come back to the dentist and say, you can't do that. According to my agreement with our insurance agreement with you as a dentist, you agree to provide a crown no matter what's on it for the price that we negotiated. So number one, they're wrong as an insurance company because they give patients the liberty to purchase these things, you know, purchase extensive or more expensive dentistry at their free will. But so the insurance companies contradict their own contract with the patients. But the problem with this is that once the patient hears from their insurance plan, oh, you actually don't have to pay that $5,000 fee. It makes the dentist look like the bad guy or the bad guy.

Right?

And now the dentist is stuck with a dispute between the patient on this particular cosmetic elective that the patient wanted and agreed to. To avoid all of that, just use an insurance waiver, have a direct payment relationship with the patient on the non covered service component. In this case, it's Anything in the range of cosmetics, the durability of a zirconia crown, if you're adding any special material to that particular unit, or any form of dentistry, anything outside of the functional and fitting component or basic component of dentistry that you're offering the patient, anything that's above and beyond what the insurance is designed to cover. The patients can freely choose to receive those procedures and pay for the difference in costs at their own expense. Anything there Drew, that you want me, want me to recover. Any questions on that so far?

Yeah, no, that's. That was super helpful, especially around the legality piece because I know that everyone is going to have questions on, you know, oh, well, we're actually getting the fee that we want. But is this allowed? Because we've been told for so long the insurances are crippling us from a margin perspective. So I'm glad that you touched on that part. You also talked about this insurance waiver, and I think it's such a key piece because I think what you're saying here is not only do we not bill insurances for this additional charge that we're implementing, but the reason that we're allowed to not bill insurances for non covered services is because we're having them sign this insurance waiver form. And this insurance waiver form is basically just stating that your insurance is covering X and we're doing Y. Here's the difference between X and Y and that you, the patient are coming out of pocket for that difference. Is that more or less how to execute that?

That is correct. In fact, when I build an insurance waiver form, I'm very specific on what it is like for. We'll use the Emax zirconia, the Emax crown as an example in that Emax waiver. So you can have a blended waiver in terms of the clinical informed consent, and then you can add the financial inform informed consent into that one waiver, which is a good idea, you know, to sort of create more power behind why you're having a patient agree to this is you want them to know the risks, you know, of the procedure, whatever it may be that you're required to disclose clinically. I include the financial components, including the insurance waiver in this agreement to indicate that, you know, Emax is a lithium disilicate material that allows the crown to look like what it's looking like. You know, it allows it to look, look like your adjacent teeth, you know, your beautiful adjacent teeth that you already have.

Right, right.

You know, without, without using this, this lithium disilicate material, you would have a crown that would look off color, you know, and then we would have to apply different shades and whatever it may be. But, but in essence, in an effort to get your tooth that you need to look cosmetically pleasant compared to all the other teeth that you already have, an Emax crown is what we would recommend. Now, your insurance plan will only cover the crown for the reasons of decay, but they're going to cover a very basic crown unit, the Emax component, the cosmetic component. You agree to pay for those things out of your own pocket. So in the entrance waiver I mentioned to the patient in a very short, maybe two or three sentences that it's been explained to the patient the difference between insurance coverage and non covered services. The cosmetic component, that the patient is fully aware that the cosmetic component of this treatment cost X amount of dollars and that the patient is in agreement to pay for that in addition to any co payment or insurance out of pocket that they would owe. I want to make it very clear for the patient to know that this is not being sent to insurance. It's 100% elective. And the reason why is because sometimes the patient will take this form to their insurance plan and say, hey, why don't you cover this? And if you do cover this and my dentist wasn't aware, I'd like for you to cover it. When the patient takes that form to their insurance plan and now the insurance plan calls you because they will, they'll say, hey, patient so and so brought this form in and we understand that you upcharge them for a crown. At that point, my first question is, can you share with me the name of the patient and I'll look that patient up in the system. If I see there in my system that this patient signed a high tech waiver at that point, my response to the insurance plan is, under the HITECH Act, I am prohibited from having any discussion with you for any treatment. The patient may or may not have received outside insurance coverage. And that's the end of the conversation. You can, you can ask me questions about anything that we submitted to you by way of coverage services, but according to the HITECH act, I cannot answer any other questions about anything that has not already been submitted to you. The insurance plan will respond with no, no, no, no. You actually have to tell, yeah, you have to engage us in a conversation because you're in network provider at this is when I become firm and say, okay, I'm going to be very firm with you. If you're asking me to violate a federal privacy law. Then let me get your name and your employee ID number and that way I can, you know, I'll report it to the Office of U.S. civil affairs who governs HIPAA and HITECH violations. Let's see what they say. Okay, what's your first name? How do you spell it?

Right.

At that point, though, sometimes they just hang up. Like a lot of times they hang up because at that they know that you know what you're talking about, you know?

Right.

But going back to the consent form, you have to make sure it's very, very specific. And you're preparing the form for when a patient, because you will have a patient take this to their insurance. You just want to make sure that it's 100% clear. And I even recommend putting the acronym HITECH somewhere on there. This is a hitech insurance waiver. Because most insurance reps don't even know what HITECH is. But once it gets to the insurance legal department, at that point they almost always instruct their, their provider relations. We got to drop this. We can't ask these, these dental practices to disclose height, high tech protected information that the patient agreed to. The patient can share it with us, but we can't ask the dentist to violate federal law.

And for my listeners, I think that Ben just gave us a wealth of really important pieces of knowledge there. So if you need to rewind back and I think the first point that I want you to focus on is the dialogue as if he were the dentist. This non cover service component to the patient. He did it in about two or three sentences. It's concise. They got the point across. And I think it's very helpful for any, you know, this goes all the way down to the treatment planning side of dentistry and the selling aspects of dentistry. Right. It's all about patient communication. And so I think he did a really good job of, of giving a concise statement to the patient as to why and then giving them their options. And then the second piece that I want you to focus on is his conversations as the dentist or the practice owner with the insurance company. Very, again, short and concise. And it's powerful to know your legal rights in this world because with that knowledge you can make a lot of, a lot more progressive headway. So those two things I want you guys to go back and listen to because I thought he did a really great job. The next piece is more of a question for Ben and does your company, when you come in from a consulting aspect, do you help them with this waiver form. Do you have maybe a template or a design that you share with them? And do you have it all the way down to the type of unit that you're using? Emax, Maybe it's gold or whatever it may be?

Yes, absolutely. So our clients don't have to write these consent forms, rewrite them for them. We have a legal team that actually writes them for us. But we always advise that every dentist has an attorney on retainer because in the end our attorneys will protect us. But you always need to consider having an attorney to protect you. And if clients don't have attorneys, we have all kinds of recommendations for attorneys that are familiar with this. It doesn't cost thousands of dollars. I don't want the entry point of getting into this concept, the financial burden or the financial barrier to be there. Don't worry about that at all. The important thing is that if you go down this space of non covered service billing. Yeah, we do help everybody, we do help our clients in terms of training, making sure that your team members are prepared. The biggest thing that I see with most of our clients is that the dentist is 100% bought in or the business owner is 100% bought in. But the team members start to resist. And that's what you have to overcome as a practice owner is getting your team members to buy in. So we have really good training to get them to buy in. And it's almost as simple as, you know, front office team members don't really understand or don't know that they're the number one asset of the practice, but they're also the number one expense. You know, payroll is number one expense in every business, almost every business, without the appropriate funds, without the appropriate rate of collections or the appropriate fees. Not if you don't, if you're not collecting what is necessary to run the business. Oftentimes you find that getting rid of a team member or two might be your only option. Right. In order to keep the business running, where the dentist would then take on more business responsibility. Right. And I see that happen every single day where a dentist has no choice but to let go their insurance coordinator because they just can't afford them anymore when it comes to non covered services. And the way I explain it to front office team members is that you are an asset of this practice, but at the same time, you're the number one expense of this practice. And if we don't collect the right fees that are commensurate with the quality of dentistry that's being delivered, it's a Threat to you as an employee. This is a threat to your job.

No, you're. You're right. And I love how you explained that commit fees being commensurate with the, with the work and quality provided such a. A key aspect that a lot of practice owners learn too late in their career. And you're ultimately. All we're trying to do with this, with this non covered service element, is bring your margins back in line to allow you to keep practicing dentistry at a high level, to allow you to keep bringing in the equipment that you need to. To continue practicing at the cutting edge of your craft. And, and, and so some of these things are subtle that Bender's talking about, you know, communication with staff. You know, ultimately, if you work, if you work with us at practice, cfo, we're going to give you the business consulting sort of prowess to go and, and be firm with staff. But for those out there that don't have a consultant to pep talk you into giving the right conversations, this, what Ben is just saying, and how you talk to staff is very key because you should never let your staff be. Dictate your business practices, your business strategy and how you go about implementing that. But it is also important to explain to them in a way that makes sense so that they can understand and join and get on board with you. So I really do appreciate that. It seems like Ben has had a lot of time in dental offices, for sure.

Yeah, no, it's. It's a. It's an ongoing battle. In fact, earlier today, I was recording another webinar series with the ESS Group up here in Utah. And before that recording, the host got a phone call from one of their people, and it was all about. It was about the same thing. You know, the dentist is on board to get this issue resolved, but they had team members that were resisting. You know, the team members were sort of dictating the doctor's decisions. And sometimes, you know, you want to be fair as a business owner to view what is actually a threat to the business and actually what's not. But never let your team members run the business.

Right.

You know, because in the end, when it comes to things like this, you're absolutely right, Drew, is that you may be missing out on hundreds of thousands of dollars, if not millions for some of you in lost opportunity. You know, and so when I approach team members on these issues where a team member is not bought in, I always explain it from that perspective. You're an asset. And I know it might seem a little bit uncomfortable to ask the patient for a little bit more money. But I guarantee you once you go through the training and you do, you go through your first patient, you'll be like, that wasn't that bad. You go through your second, third and fourth patient. And like, what the heck was I nervous about? This is so easy, you know.

Right, right. I, you know, it is, it's one of those things and it's not. And again, like this, it's, this has such a strong parallel with treatment planning as a whole. The communication aspect, how you deliver it, how the patient receives it, the psychology behind getting people to, to do the type of dentistry that is better for them. And so I, I do love these types of conversations. It's got an element that's not rules based, you know, and that, that, that's always drives some really fun conversations. So, you know, continuing just a little bit further on this non cover services topic, Ben, so we have like you mentioned, materials as, as it, as it relates to emacs and the different types of labs that are out there for, for you know, implants, restoration, full arch, you name it, there's some element to that. What are other procedure codes? What are other procedures that you see non, non covered services playing a role and.

What areas are you seeing that in?

Absolutely, you mentioned most of the highlights. I think mouth guards are another one.

There's, you know, the labs for mouth guards aren't, they're not cheap, especially if you want to get a really good mouth guard.

There's a code for mouth guards and most of the times the entrance allowance or the fee for the mouth guards or the night guards, they wouldn't even cover your labs. So anytime you're faced with paying a lab fee or a material fee or material component, that's an opportunity for you to take a look at. Okay, is the insurance plan sufficiently setting up, well, a fee that is sufficient to cover the, the cost of care and to allow me as a business owner to generate some profit. And if the answer to those questions are no, at that point you would want to implement this non coverage service rule in the sense that on the night guards or mouth guards, you have your insurance allowance, but you also have a non covered service fee. I wouldn't go too crazy with the non covered service fees. As an example, the night guards, typically the insurance allowances less than $100 in a lot of situations or less than $200, but your lab fee is $300 to me. You know, I would look at the time and, and costs associated with the delivery of the mouth Guard or night guard and then set my non coverage covered service fee from there. But keep it simple. You can always raise the non coverage service fee. And my opinion about what's considered too high in terms of fees is whatever the market will bear will be your indication. And we learned this with Emax and Zirconia crowns. We started at $49, and then we started to raise it to 89, 99, 149, 200, 250. And at that point we started to see resistance by the patients and, you know, the old economic classes that it took in college. Once we started to see the market reject the 249 fee, we brought it back down to 140, you know, 149 to 199, you know, with a 98% compliance rate among patients that move forward with crown treatment.

So in terms of setting fees, I would use that same methodology as you want to raise that incrementally over time. Implants, a lot of practices do all on fours or multiple implants that are not all on fours. Multiple single implants. And if you look at dental insurance coverage versus implant services, you know, a single implant placement is $2,000 in most parts of the country. Right. That's the full fee, not the insurance allowance. And then you have the abutment, if it's an abutment retained crown or a screw retained crown, that also cost, you know, 1500 to another 22, $2300. You know, depending on where you're at in the country, a single implant case would likely cost the patient 3 to $5,000, but you have $1,500 of insurance benefits to use. And then when you stack the codes for the entire single implant case against insurance fees, the max allowance is likely only going to be $2,500. Right. Your labs for the entire case is likely going to be closer to $1,800. On the higher end, that is. But needless to say, with those numbers, you're not making any money. Right.

So for implant cases.

Yeah. And that barely covers the time of the employees that work with you. So in essence, for implant cases, I would look at it on a single unit case all the way down to multi unit case and make sure at the very least that you're offsetting the lab work that's associated with the implant case and some for all. On four cases, we have clients that charge $25,000 for a single arch of all on fours. And that's implant placement all the way down to the final restoration. You can't do this if you're submitting this to insurance. In fact, three weeks ago, I got a call from a client in Illinois, submitted all the codes for an all on four to Delta Dental. And it ended up coming out to be a $25,000 case. But Delta Dental reprocessed everything and kicked back the EOB and said, okay, this is disallowed. This is disallowed. This is disallowed. These are the only codes that we'll actually cover, which means that we'll pay $1,500, but the patient's total out of pocket is going to be 3,800. The lab fee for this particular case was about 4,500. So this dentist was faced with losing money. You know, after paying employees and paying the surgeon that placed the implants, this dentist was faced with losing a few thousand dollars on this case. The best way to avoid that is using an insurance waiver, submit what is necessary to cover the implant cases to max out the benefits and have a financial arrangement with the patient to indicate that $25,000 is what it's going to cost minus whatever your insurance will pay. And so, you know, everything that's not submitted to insurance on the implant case would be included under that insurance waiver.

Other areas, I think we covered most of them. Crowns Bridges. I would be very careful not to go too crazy with this. I know a lot of offices charge sterilization FE to patients for every single procedure. What you find when you add like, even PPE fees drew, like, remember last year when the cost of gloves just skyrocketed significantly and the insurance industry is like, oh, we'll pay you $9 here and there. But not all insurance companies did that. So the dentists themselves started to institute PPE fees and bill that to the patients, because that's what the ADA said, hey, use, use this. They created a code specific for ppe. Well, once the dentist started billing that to the patients, there was a huge uproar by the entire country.

Right.

There are news articles saying dentists are nickel and diming patients by charging them PPE fees when they should be covering it on their own. The public just wasn't aware of these particular issues that medical practices and dental practices were facing. But the point that I'm trying to make here is that you want to be careful and not going too crazy with this concept and charging a material fee for everything. Be reasonable. Because we have, we have, well, never clients of ours, but we know some people that some dentists for a single extraction you know, if I were fif with, well, I am uninsured, but if I were to go to a dentist here in Utah, I needed a tooth extracted without, you know, any.

Any major anesthesia, probably cost me maybe $300, $250, $300. But there are some practices here locally that for one extraction, it'll cost you two grand because they put all these, you know, sterilization fees and.

Potential bone graft fee, a scatting fee and all this. And when you look at the treatment plan, it looks, it's very obvious to the patients like wow, you are really trying to oversell something here. And I think to dentists, you know, most dentists want to stay away from the cells component of dentistry. Right. Let the treatment, let the treatment be decided from an educational perspective where the patient proceeds based upon the clinical need necessity.

Right.

So that's the number one thing that I see in terms of patient pushback is that when you add too many things on a treatment plan from a non covered service perspective, at that point it becomes suspect to the patient and then you, then you're at risk of getting reviews and a reputation among the public that you overcharge, you know.

Agreed, agreed. And this brings up some really high level economic principles as well. You have to know your market and the fees being charged by your immediate competitors which are dictated by supply and demand forces in the dental space. You also have this element of herd immunity because you have so many high functioning practices applying this non cover service charge to implants, crowns and other lab related work that the public, whether they know exactly what you're doing from a technical billing and insurance perspective or not, will have a general idea what the total out of pocket cost should be in their area for a given procedure. And that total out of pocket amount that they deem reasonable most likely already includes the non covered service component due to this herd immunity factor. So what Ben is saying is allow basic economics to determine how much and where you're applying these non covered service elements and don't go crazy. Otherwise you could potentially detract rather than accomplish the goal of adding value and attractions. I'm sorry, and extractions was the example that he used, which I felt was a Great one with 2000 being well over, well over market. Ben, I know we don't have a ton of time left and we still have so many more topics that I'd like for you to cover for our listeners. So let me see here. The next aspect of the billing world that I like to cover is sort of Automated code blocks. I, I don't necessarily know if that's the most eloquent way to say that, but what I'm envisioning is, you know, you have your common set of procedures for a 2740 code, right? You got your build up, you got the actual crown, everything else that goes along with that procedure. How do you go in and say, okay, for this procedure we've got all, let's say it's 15 or maybe it's 10 to 15 different, or 5 to 15 different codes, you know, including all the build up codes and everything that goes into this procedure. How do you get their practice management software systems to a place where, you know, they could easily say hey assistant, it's going to be code block 1A. And then all 5 to 15 of those codes with the write ups, associated write ups that go along with, with the billing are all pre, sort of pre populated. Maybe they have to make some small tweaks. But more or less it just adds this efficiency to, to, to the billing process and it reduces claim rejections and it speeds up the time in which this the staff because they're not writing up everything. So maybe talk to that piece a little bit as well.

Absolutely. So most dental practices are familiar with the standard form of coding, right? You know, if you're doing a CO that has a need for a buildup, most practices will know how to build that claim and treatment plan in their practice management systems. And this is a really great question because when you're adding non covered services, you need to have a protocol to remember to not submit non covered services to insurance in situations where patients sign an insurance waiver. So my first recommendation is that number one, we're not using the traditional unspecified codes like the 1999s or 2999s. Instead we want to create our own in house codes. Now many of you are familiar with that concept where you have your whitening kits that are created in your practice management system using your own code terminology, right? So for a crown, as an example, if I'm doing an Emax crown and I want to do a material fee for Emax crowns, number one, I will create an in house code that is not recognized by current dental terminology. So a basic example is I DO E for Echo 2740 or E1234. Either way, if you do D, start the your in house code with the letter D. At that point you're conforming with cdt, current dental terminology. So rule number one is you don't Want to conform to current dental terminology and create a non traditional code. So E1234 or 1, 2, 3, 4 5, whatever it may be. The second thing is that in the code description, you want to start that code description with the acronym HiTech. Why is because if you're ever audited, you have to by law omit anything noted with HITECH with a short explanation to the insurance person. Anything in here that you see that is omitted is protected under the HITECH act. And that's, that's all I can share with you at this time. End of discussion. Legally, end of that discussion. But also it's a reminder when you're building, so here, when you're building the treatment plan, you want to show high tech codes.

In an effort to show the patient their responsibility. But when you go to submit that claim, you want to make sure that you're building the claim without anything that has high tech noted in that particular batch of claims now going, circling back. So you, in your code description you have high tech and then, and then I put the actual description of what it is. It's very important to remember that you, you don't want to duplicate CDT definitions. So if you're doing an emacs crown, I don't want to put emacs crown in that code description. Instead, if the purpose of Emacs is, is to deliver high level cosmetics, then I will put something like lithium disilicate cosmetic properties. If it's a zirconia crown, again you don't want to put zirconia crown. I put highly durable, long lasting properties. Something along those lines where you will likely have the best value conveyed to the patient is if you explain that code from a treatment planning perspective on value. You know, high cosmetics, high durability, things like that. And then you create your feed. So again, remember, the rule is it's an in house code. You'll know this as a team and have a pretty good understanding. Especially if you start this concept maybe with just one procedure at a time. You know, a lot of our clients start with the crowns first. Once you become familiar with an in house protocol on how to include the high tech codes on the treatment plan but exclude them once you build the claim, it becomes very, very systematic. From there, where you have a really good protocol that isn't burdensome and doesn't create a whole lot of extra work for you. Because at this point it's just a matter of unclicking one code or two codes on a treatment plan in order to get the claim ready to submit to insurance. Did I cover your question there?

Yeah, no. I think one more piece of that, you know, that's makes so much sense and I think that that dialogue around non cover service write ups and is super important. But what about just like common leet codes that you are actually billing to insurances and you know, the, the blocks, the, you know, all of the codes that sort of appear together typically, you know, for, for a given procedure are you help, can you help them or do you help them in your consulting piece sort of develop write ups for those different procedure codes, make sure that they're not missing any procedure codes just to sort of bulletproof the insurance billing process so that when they go there's less rejected claims and there's less time spent with write ups, that sort of thing.

Good question. Yes, we definitely help with this. This is, there are two things with. This is number one, just having a really good understanding of the CDT codes. Fortunately for most practices, whether you're a specialist or general dentist, you have you know, specialty maybe 20 codes that you do almost exclusively, right? So that's 20 codes that you have to, you have to memorize and study those code definitions so that you know when and when not to use them. General dentistry, it's anywhere between 35 to 50 codes that, that are used frequently in the practice. So you, in, in general dentistry you engage in a little bit more study because you're using more codes. But that's, that's still not that bad. So that's the first step is you just have to make sure that you're a master of the codes, particularly your top codes that you're using the most. Secondly, you have to understand the insurance policy and let's use the crown and build up example. A lot of times practices will report the crown on the seat date, right? So when they, I mean, excuse me, the prep date. When you prep the crown, you submit the entire claim. Most insurance companies don't want you to do that. They'll say, well you can report the prep work on the prep date and then report the seat, the crown seat on the seat date. So you're submitting two different claims. The best way to know each insurance company's policies is to request a policy and procedure manual. And that way you know the difference in how each of these plans want to see the codes sent to them. Otherwise, you know, for CIGNA as an example, if you submit the entire claim, including the, the crown code on the prep date, the buildup will actually be bundled with the Crown when you get the EOB and the insurance will say, well, this, the crown and the buildup is considered one service in order for you to unbundle that. In the policy and procedure manual by cigna, it says, well, for that situation, all you need to do is report the seat date. And when you report the seat date, that will allow us in our computer to unbundle the procedures and pay for them separately. So when it comes to insurance administration, it takes some time and training to learn these policies. So you have the standard CDT policies that the insurance companies agree to, but you also have each individual insurance company on what their policy and standard is. And once you know those, you will have in your own mind a very clear understanding of making sure that the set of codes that you're using for a procedure are the appropriate codes and you're submitting them at the right time, just like that crown and build up example in an effort to avoid the unbundling. The other part.

Oh, sorry, Drew. The last part I was going to say is that in this day and age where you're submitting a clean claim, it's not uncommon for insurance companies to deny them, saying, well, this just doesn't fit our clinical criteria for coverage. And then you resubmit the claim with an appeal saying, well, actually this is medically necessary and we submitted the claim clean the first time around. And benefits are available without treatment, patient's gonna suffer, whatever it may be. You can have templates for those if you want. If you see a consistency in denials around, you know, the fact that, you know the insurance company is using the same language doesn't fit the clinical criteria. So you can create a template appeal. But what I would say is that, and this is probably for another podcast, is you can actually challenge the insurance company on a delay tactic if you know your state law, like a lot of state laws indicate that in dentistry, if it's a clean claim, meaning it's medically necessary, benefits are available. You either did a pre authorization or a verification of benefit to verify that there was eligibility for coverage. But the key thing being is that it's medically necessary, claim is submitted and the insurance company engages in a delay tactic. A lot of states have a law to indicate that delay tactics are prohibited if there's no impropriety or defect to claims. Meaning you didn't you use the right CDT codes. Your narrative was clear and didn't look like a, you know, it was using a professional language. And according to ADA standards at that point, from a legal Perspective, the insurance plan is on the hook to pay that claim the first time around. So if you know the laws, you can actually quote that law in the appeal saying, hey, this was a clean claim according to code, such and such of California law, blah, blah, blah. At that point, if the insurance company denies it again, boom, you actually have a solid case to present to the insurance commissioner on behalf of the patient to get the insurance company to stop engaging a delay tactic. And if you do that, engage the insurance commissioner or even cite California law or state, any state law, depending on where you're at, what you will find is that those denials will lessen over time, that the insurance companies will start to get it while this practice is probably talking to an attorney. So we don't want to, we don't want to run the risk of getting sued by these people because it seems like they know what they're talking about.

So, guys, Ben is such a valuable resource and this is such a valuable topic. And I think you can already tell the breadth of knowledge that not only does he have, but that you need to arm yourself with in order to be a high level practice owner. And for that reason, I'm going to have Ben come back and we're going to do a part two to this podcast series because I think it's that important. But for now, we're going to say goodbye to Ben and we'll. He'll be back on the show here very soon. Thanks so much for your time, Ben.

Thank you, Drew, and thanks everybody. Have a great day.