Every dental office should follow some form of a dental billing process.
It doesn’t matter if you are a startup office or an established clinic. It’s a simple fact that many dental offices across the U.S. struggle with this process. You may have just stepped into this new world of dental billing, and not know up from down. We get it. It can be complicated and super detailed.
If one part of the process is broken, it can seriously affect your collections. The dental billing process is performed best as a team effort, composed of various administrative employees. Working together will ensure there are no kinks in the chain.
Our company, Dental ClaimSupport (DCS), was founded on the principle that not all dental offices have a streamlined dental billing process. A couple of the founders of DCS actually worked with a small group dental practice composed of 8 offices and realized that all eight offices did their billing differently, even though they were part of the same umbrella.
We wondered: Why does everyone do this process differently? Then we thought if everyone here handled billing differently, surely other offices across the United States were. We were right.
If you want a Free Dental Billing Assessment for your office, you can get assessed here.
Yes, we help offices across the United States with this dental billing process. However, this can be achieved on your own, and we want to share with you how. In this article we’ll clearly detail what the dental billing process is and why it’s vital to successfully running your dental practice.
You will not be shortchanged in this article. Get ready for a full breakdown of the entire dental billing process. This will be your ultimate guide to the dental billing process and getting claims paid!
What is the dental billing process?
The dental billing process is the path in which you will get paid in your dental practice.
We have broken out the process into steps for you. There are 2 Phases, with 8 Steps in total.
It begins with the patient entering your practice. It ends with the claims being paid and posted.
The life-cycle of a dental claim should be seamless - plain and simple. Implement a simple plan, and your office will reap the benefits of higher collections, lower insurance aging reports, happy patients, and a peace of mind.
The two phases to the dental billing process - The life-cycle of a dental patient and the life-cycle of a dental claim. Below we will break down the steps that make up each phase.
Phase 1: Life-cycle of a dental patient
1. Dental appointment is created
2. Data entry into the dental software
3. Insurance verification is performed
4. Dental appointment is completed
Phase 2: Life-cycle of a dental claim:
5. Dental claim is created and batched
6. Dental claim is submitted
7. Insurance carrier processes and pays claim
8. Payment is posted in the dental software
Many dental offices will say they have one to four employees handling this entire process, all depending on the size of the office.
But who is responsible for what? Does one or two people handle the patient duties, meaning appointment, check in, insurance verification, etc? Does someone else take over during the life-cycle of the claim? Is it a free-for-all where whoever has a spare second tries to handle what needs to be completed?
If this sounds like your office and a situation you face daily, you probably do not have a defined process in place. If you don’t, your collections could be taking a serious hit.
First things first, you need to have a structure. Make sure you know who is responsible for each step in the billing process. Each team member needs to be held accountable for his or her tasks.
Here we go! Strap in and get ready for an explanation of each step and the importance of a streamlined, continuous flowing dental billing process.
Steps to the dental billing process
Phase 1: Life-cycle of a dental patient
1. Creating a dental appointment
This process is quite simple. Every dental practice management software has the ability to make appointments, and they all work similarly. A patient has either called your office, your call center, or booked an appointment online.
What’s important is obtaining the patient’s insurance information and demographic information at this initial contact. This information is accurately entered into your dental software “creating” a patient, if they haven’t already been established, of course. Next, is setting the appointment.
Hygiene appointments are usually quite seamless as most patients are coming in for the routine dental cleaning and checkup. However, if a patient is seeing the doctor, the scheduler needs to make sure enough time is allotted during the appointment for the doctor to complete the work.
Most providers, dentists and hygienists, like appointments made to fit their schedule and structure. An example would be some doctors prefer high production such as crowns, implants, bridges, etc. in the morning, and fillings and more basic procedures in the afternoon. This allows for a “flow” of sorts and predictability in the daily schedule. Make sure you have an understanding of how your providers want their patients scheduled. You will see this positivity impact the day-to-day flow as well as the communication between the administrative and clinical teams.
2. Data entry into your dental software
The next steps in the dental billing process are entering the patient’s PHI as well as performing insurance verification. Correct data entry is a necessity in these steps. Inaccurately inputting patient information or insurance information will ensure your claim does not get paid. This is a no no!
Inaccurate data entry could be anything from wrong dates of birth or misspelled patient names. It can also be on the insurance side, where incorrect insurance ID numbers, group numbers, or payer IDs are entered incorrectly.
This should be 100% avoidable. Double check and make sure all data entry information is correct before moving on to another task or patient. This only takes seconds and can save you hours of headache in the future. Time is money.
3. Insurance verification: How to? What’s the importance?
Step 3 in the dental billing process is performing insurance verification. Insurance verification is defined as, “the process of checking a patient's insurance coverage and benefits prior to the date of service to ensure payment for services”. In a nutshell, insurance verification makes sure the patient has active coverage, and you know what procedures are covered and how much will be paid by insurance for each procedure if you perform them.
Insurance Verification is typically done by visiting insurance web portals or calling the insurance carrier. For either, a “full breakdown” of benefits is needed in order to truly understand a patient’s benefits. You can utilize the insurance web portal or ask a representative on the phone for a full breakdown of benefits. What is a full breakdown? This means what procedures are covered, at what percentage are they covered, has the patient already used any benefits elsewhere, what is the patient’s plan maximum, etc.
In addition, you also want to verify any frequency limitations, age limitations, and certain clauses such as waiting periods, missing tooth clauses, and replacement clauses. This information will help you collect from the patient upfront, meaning before they leave the office after the dental visit. You know exactly what insurance will pay (without having to send a pre-determination), and exactly how much the patient will owe you (if you have successfully entered in your PPO fee schedule.)
Believe it or not, insurance verification is not done in many offices across the United States yet is the single most important task you can perform in any dental office. Why? Among many reasons (more on this later), the “0 balance system”.
If your dental team inputs all patient information into your practice management software correctly (data entry) and verifies your patient’s benefits (insurance verification) you should not have any issue sending the patient’s claim accurately. And again, you will know how much will be covered by insurance. If you know how much will be covered by insurance, then you know exactly what the patient out-of-pocket should be.
Collect this patient out-of-pocket before the patient leaves the office after the visit. Once the claim pays, the patient is left with a $0 balance, a clean ledger, and you never have to send invoices to patients. This again, saves time and money. You can probably see a trend here...
Failure to perform insurance verification leads to unpaid claims and lost revenue. Your dental team will also not be able to explain the patient's benefits should the patient ask. This leads to lower case acceptance and lost potential revenue. Rule #1, always perform insurance verification for every patient.
4. Completing an appointment for a patient
Steps 4 and 5 involve checking a patient in for an appointment and releasing the patient after the visit. As stated above , your dental team should have already created a digital chart for this patient with the personal and insurance information. Your team should have also completed insurance verification, making sure the patient is active with coverage and eligible to be seen by your dental providers.
You should know what your patient is being seen for that day in your dental practice. However, things may change or it could be an emergency or walk-in (unscheduled) patient. After the patient completes the visit, make sure what was done in the dental chair matches what you have in your dental software.
This will make sure you send an accurate claim to the insurance carrier. Because you performed insurance verification and loaded the patient’s benefits correctly in your dental software system, you will also know if the patient has any out-of-pocket expenses for the work completed that day. Remember, always collect before the patient leaves.
Lastly, try to go ahead and make sure patients have their next appointment scheduled. This could either be for future treatment presented to them that day such as the need for a crown, or filling, etc. Or it could simply be a patient’s 6 month recall visit. Either way, to avoid having to contact the patient again, be proactive and schedule the patient while they are in front of you.
Phase 2: Life-cycle of a dental claim
5. Creating and batching a dental claim
The next steps in the billing process starts the life-cycle of a claim. Your patient has already been seen, so now it’s time to send the claim to insurance in order to get paid. All practice management softwares have the ability to create a claim from procedures completed that day.
There isn’t much to creating and batching a claim, and most practice management softwares work similarly. Batching a claim means putting it in queue to send later on with other batched claims. This is done directly after the patient completes the appointment and leaves the office. While checking out, your front desk should create and batch the claim. This will indicate how much is expected from insurance and how much is expected to be out-of-pocket to the patient.
Most dental teams elect to batch all claims throughout the day, then send them all together either at the end of the day or the next morning, as opposed to sending claims individually. Fewer amounts of claims transmission typically equals fewer issues with claim submission. Imagine seeing 100 patients with insurance in one day. Do you want 100 transmissions or 1? Time is money.
Lastly, always have your providers, dentists and hygienists, look over their day-sheets before submitting all claims. Day-sheets are essentially a report that lists the patients seen that day in the dental office and what each patient had done.
In order to send accurate claims to the insurance carriers, take a few seconds to make sure the procedures done for each patient are correctly documented.
Next, you submit the claim. How does this work exactly?
6. Claim submission through a clearinghouse
All dental offices should be using a clearinghouse. What is a clearinghouse?
Let’s get technical. “A private or public company that provides connectivity and often serves as a ‘middleman’ between healthcare providers and payers.”
Let’s get simple. Clearinghouses make sure that claims sent from your dental software are distributed to the correct insurance company electronically.
So let’s take the “100 claims with one transmission” example from the section above. All of these claims are transmitted to the clearinghouse. Then the clearinghouse makes sure information is correct with each claim, then sends each claim to the correct insurance company.
How does the clearinghouse know which insurance company is correct? Great question. The answer is payer IDs. Payer IDs are 5 digit/alpha characters unique to each insurance company. If you have the wrong payer ID entered in your dental software for an insurance company, the electronic claim will not get there. Remember why data entry is so important again?
If you are not using a clearinghouse or are looking for one that fits your practice, make your decision easy and compare what are the best dental clearinghouses out there and understand the different functions of clearinghouses. Fully understanding dental claim submission will ensure you are sending claims the correct way and being paid by insurance companies.
We’ve mentioned that you need a clearinghouse. This remains true. However, having a clearinghouse is moot unless you follow some basic claims submission guidelines:
- Make sure your 2019 ADA dental claim form is set up properly with correct billing and rendering provider information
- Pay attention to the dental codes you are using. They need to be accurate.
- Your patient and patient insurance info needs to be correct. No mistakes!
7. Insurance carrier processes and pays dental claim
We are almost there! With hope, all of your dental claims pay, and you never have any issues. To be 100% honest, that would be a fairy tale. By taking the necessary steps you’ve read about so far, you should drastically limit the amount of unpaid or unprocessed claims. We’ll discuss unpaid and unprocessed claims shortly.
Let’s talk about the dental claims that do pay. Insurance carriers send payment in a few ways: virtual credit card (VCC), paper check, and electronic fund transfer (EFT). As a dental provider, you can essentially opt in to whatever form of payment you want. What’s important is making sure whatever you decide is the best fit for your office and dental team performing the billing.
Dental virtual credit cards:
VCCs are printed on sheets of paper accompanying the Explanation of Benefits (EOB) provided by the insurance company. They show an image of a “credit card” including a credit card number, expiration date, and the exact dollar amount loaded on the card for the claim being paid. Beware! VCCs are also accompanied by the dreaded merchant fee. Do yourself a favor and opt into EFTs or continue to receive paper checks. Find out why VCCs may be bad for your practice.
Dental paper check:
Listen, I get it. In this day and age, why get a paper check when the way of the world has gone so digital? Also, there are other ways of being paid such as those VCCs we just discussed or EFTs. Well, simply put, there is nothing “wrong” with check payments. A common misconception of check payments is that they take too long to actually receive. However, most insurance companies will get a paper check to you within 12-18 days. What’s also funny is VCCs have to be mailed or faxed… so how would they be that much quicker received? They wouldn’t, and they cost you merchant fees.
What’s important is making sure you are comfortable with how you receive your payments. Less avenues of being paid typically lead to less mistakes in the accounting department. If you are comfortable with a slightly longer wait to receive payment, paper checks aren’t going to hurt you. Another benefit is you don’t have to track down an explanation of benefits when you receive a check payment as the two always accompany each other in the mail.
Dental electronic funds transfer:
EFTs have become the most popular form of insurance payment. Personally, it’s easy to agree with this. EFTs are directly deposited into your business bank account, and the claim payments are much faster, usually outracing paper checks and VCCs by a week or more. Not all EFTs are created equal though, and some insurance web portals are not as user friendly as others.
With EFTs, you have to go to the insurance web portal from which you received the EFT in order to retrieve the electronic remittance advice (ERA/digital EOB). This is the only way you can actually post the dental claim payment. If you don’t retrieve the ERA, then the claim is never posted, closing the claim out, yet you have actually received the funds in your bank account. That means the claims will still show as outstanding on your insurance aging report, inflating it. This is a common problem in dental offices.
Long story short, be consistent with the way you receive payments. If you only see one patient with a random insurance company named “X”, don’t opt in to EFTs with “X” as this creates more work for your billing team. Just get paid by paper checks from that insurance. However, let’s say you see tons of Cigna patients. Cigna would be good to opt into EFTs. The website is easy to navigate, and Cigna will pay many patients on one bulk EFT that hits the website every few days. Your billing team will know when to visit the website in order to post a large payment.
8. Posting the insurance payment in your dental software
The final step of the dental billing process is posting the claim payment. Posting the payment does a few things for you:
- It records the payment in your practice management software. This should match up directly with your deposit in your bank account.
- Posting the claim payment applies a credit to the patient’s ledger. This either leaves a balance owed by the patient that needs to be collected, or hopefully creates a “0 balance”.
- It removes the claim from the insurance aging report as the claim is no longer “outstanding”.
There is also an ideal way of posting insurance payments.
You should always post payments by procedure
What does this mean? Posting payments by procedure means allocating exactly what was paid for each procedure/line item to the correct procedure and line item in your dental software. There is more to the technique of why you should post dental insurance payments by procedure, however there are 4 main benefits to posting by procedure:
- Accurately and efficiently compensate your providers (dentists and hygienists)
- Know exactly what was paid for each procedure
- Maintain a current preferred provider organization (PPO) fee schedule
- Accurately calculate the patient’s portion and PPO provider write-off for dual insurance
Not all dental claims pay automatically. Some may have been caught up in the clearinghouse and didn’t get to the insurance company altogether. Some may have gotten to the insurance company, but needed additional information.
With claims that haven’t processed or paid, we have to research them and find out why.
Although not a “step” in the dental billing process, one of the main tasks your dental team should be performing is working the outstanding insurance aging report. Working this report simply means researching claims that are 30 days old that have not paid or processed.
An insurance aging report is a report composed of all outstanding dental claims that have been created and sent to insurance companies. Plainly put, these are dental claims not processed or paid by the insurance company and posted to patient account ledgers. Posting the processed claims and payments “closes” out the claim, which removes it from the insurance aging report.
In most practice management softwares, such as Dentrix®, OpenDental, and Eaglesoft®, the insurance aging report setups are alike. The report lists all open claims by insurance carrier. It also sorts the claims by age, hence the name “aging” report.
For example, if a patient was seen today and a claim was created and sent, that claim is 0 days old. If the same claim has not been processed/paid in 30 days, meaning you don’t have a deposit in your bank account or a check in your hand, that claim has aged 30 days and needs to be researched.
Most dental billers call these claims, claims on “your over 30 day report”. This exact report should be run (printed and looked at) and worked (claims researched) at least weekly.
Dental claims 30 days and older should be your focus as a dental biller.
Dental plans follow established prompt payment laws with most states. Depending on the type of plan, they legally have anywhere from 30-45 days to process a claim. In other words, there’s no point in researching a claim that’s 14 days old, as you’ll probably find out the claim is in process and set to pay. Don’t waste your time here. Your time should be focused on a claim over 30 days needing actual attention and research.
As much as you don’t want claims aging 30 days or more, it’s almost inevitable. You can have the safest, most buttoned-up process in place, but insurance companies are sticklers. They will find a way to deny certain claims or in a time of amazing technology, sometimes things just don’t work and you have glitches. This could be either in processing at the insurance level or in your dental software or clearinghouse. That's why someone has to be dedicated to staying on top of this report.
There are proven techniques and principles to getting these claims processed though. Knowing how to decrease an insurance aging report and do it quickly, will ensure claims don’t continue to age or be neglected altogether.
Research every claim on the over 30 day insurance aging report to find out why it’s still there. When you are considering how long it will take to clean up the report, you must factor in the time, quality, and quantity.
- The time is in the research of talking to the insurance carrier, claim by claim. You can also utilize online portals to speed up the research of the claim status.
- The quality is in the questions asked and the knowledge of how to get claims paid. You then may believe your aging report cleanup is based on the dollar amount of the claims outstanding.
- The quantity of claims can best determine how long your cleanup will take.
How do claims show up on the outstanding dental insurance aging report?
Remember this from earlier? “Insurance verification is the single most important task you can perform in any dental office. Why? Among many reasons (more on this later)...”
It was only a matter of time until we got back to insurance verification and data entry. As stated earlier in the article, not completing these tasks is a surefire way for claims to consistently flood this aging report.
Insurance verification can be thought of as the most proactive way of working an insurance aging report. No, it’s not “technically” working the report, but the more insurance is verified, the less rejections or delayed claims you have. This means the less claims pop up on the aging report as well. Taking the time to perform insurance verification will save you countless hours in the future of researching claims that should have never shown up on the report in the first place.
Not performing insurance verification isn’t the only reason dental claims show up on the outstanding insurance aging report though. The more upfront measures your dental team can take to avoid unprocessed dental claims, the better chance your dental office has of being successful.
How do I implement the dental billing process?
There you have it. You now know the full dental billing process from start to finish. There may be nuances to every step that weren’t covered in this article, but experience is the best way to learn. If you can take one patient through this process with success, there is no reason you shouldn’t be able to take a 100 or 1,000. That’s the mindset your dental billing team needs.
If you want a Free Dental Billing Assessment for your office, you can get assessed here.
Remember, this process will not perform on its own. There needs to be someone responsible, and held accountable, for every step along the way. The beauty of the process is, with time, you will be able to identify exactly where an issue lies. For instance, you will pinpoint if an issue lies between steps 3-4 or 6-7 simply because the process works like a chain; identify the kink and you’ve identified the problem.
Many dental offices have been able to adopt the dental billing process and run with it smoothly. However, many other offices have felt the headache and continue to search for help. This is simple stuff, but it’s hard to do. If you find your team struggling to keep up, or simply don’t have the time or the right team in place to handle your dental billing, you need to consider other options.
Don’t let deficiencies in your dental billing process snowball into an insurmountable problem. Outsourced dental billing could be a viable option for you. It has become a norm in our society today. With a rapid switch to remote work, and advancements in technology, dental billing can be done at an expert level from home. Keep your options open and do what’s best for you and your dental team.