Bill Klaproth (Host): This is an AAOMS On The Go podcast. I'm Bill Klaproth, and joining us today is Dr. Travis Campbell, known as the Dental Insurance Guy, to discuss what OMSs need to know to successfully work with insurance companies. Dr. Campbell, thanks for joining us.

Travis Campbell, DDS: Oh, thank you, Bill. It's a pleasure to be here. 

Host: Absolutely. So, let's jump in. So, what are some of the basics an OMS should know to successfully work with an insurance company?

Travis Campbell, DDS: I guess the number one thing is learn to actually get reimbursements from insurance companies. So it's the challenge I see come up a lot with specialists and GPs is just a lack of documentation that is needed. And of course, I mean, I've been doing this 15 years and some people have been doing it longer.

The requirements for documentation have changed over the years, which kind of leads to some frustration and annoyance. But at the same time, if we improve our own documentation, then we get paid by insurance faster and life's just easier.

Host: Getting paid faster and making life easier, always a good thing, that's for sure. So let me ask you this. I know that there are OMSs and dentists that have concerns with in-network fees. Can you explain that to us?

Travis Campbell, DDS: The challenge that comes up is making sure that the service, the fees, and the codes all match up . So, for instance, the most common challenging one that comes up is when we talk about All-on-4 services. And the question I hear a lot, is the fee in-network for the code for an All-on-4 is not even high enough to cover the lab bill.

So how do we even provide that? Well, the challenge is you know, a lot of times we want to simplify things more than they can be simplified. So something like an All-on-4 is not a single code that everybody thinks of, which is, 6114 or 6115. An All-on-4 is actually eight to 12 codes for the restorative side.

And usually another eight to 12 codes for the surgical side. And so the bigger challenge isn't the fact that the fees are too low. Bigger challenge is just not using the codes correctly.

Host: And then can you talk a bit about what to do with secondary insurance? 

Travis Campbell, DDS: Yeah. Secondary insurance. I mean, you can do it a couple of different ways. My suggestion, and it's because secondary insurance usually takes a lot longer to come in. It's hard to estimate because there's multiple different ways in which coordination of benefits will work. So my biggest suggestion for secondary is almost treat your office like secondary doesn't exist for the patient. Meaning when you're going to provide an estimate; estimate as if primary is the only insurance company and let secondary be a nice benefit bonus or whatever when it does come in later back to the patient as a credit and not as money that the office is having to wait 2, 3, 6 months to get.

Which also makes it a lot easier to estimate because there's four different ways insurance companies will process secondary payments and they all will lead to different amounts of reimbursement, if any. And the biggest challenge I ever see offices have is when they overestimate what insurance might pay and then end up leaving the patient with a surprise bill.

Which, I don't know about you, anywhere I go, if I ended up with having to pay more than I was expecting, I'm kind of upset about that. And the patient naturally would be too. 

Host: Absolutely. So then how can an OMS maximize reimbursements?

Travis Campbell, DDS: So again, that comes back to what we talked about earlier. It's about documentation is making sure everything is documented the way the insurance company wants it. And that's some of the challenge we have is we're like, well, this looks great for a dentist. Well, that doesn't necessarily mean anything because you're not talking to a dentist usually.

The other thing to think about is photos are far more important than anything else. So, like one example, insurance companies tend to dislike paying for alveoloplasty, and their excuse is that a lot of dentists are fraudulent or over billing alveoloplasty. So, for instance, alveoloplasty is intentional removal of bone, significant portions of bone, in order to, prepare for a denture or whatever later.

And yet, that's not just smoothing one little edge of the bony complex, it's actually making a significant change to it. And so if you use the code correctly, then that's one thing is just to make sure you're not misinterpreting or misusing the codes, but the second is photography. I mean, nothing's better than a bloody picture of a bunch of bone before and after, you did your alveoloplasty, that's a huge, great way to just determine, yes, this was actually true alveoloplasty and not just you pulled out the bone file for two seconds. It's documentation like that. And the fun part is a lot of times the people who are looking at these claims are not dentists. And you send them a bunch of lovely bloody photos and they're not going to want to bother looking into the details. They're just going to go, oh, yeah, something was needed here I'm just going to process this as approval and move on. 

Host: I like how you put it, the fun part. That's good. 

Travis Campbell, DDS: Yeah, I think bloody pictures are fun. I love surgery, but I realize most people in the world don't.

Host: Right. Well, those are really two important points, Dr. Campbell. One, document the way insurance companies want you to, and then photography is important. That old saying, a picture's worth a thousand words. I guess that's true. Really good points on that. So we hear a lot about HITECH HIPAA in the waivers. Do those work? 

Travis Campbell, DDS: You know the HITECH HIPAA waivers do work. The challenge a lot of people have with them is they're being used incorrectly. So for one thing, you've got to think about what any paperwork is to begin with. Let's think of consent forms for a second. Consent forms, the important part isn't that you have the patient sign. The document is only a documentation that the conversation with the patient happened, right? It's not just, Hey, sign this form and I can pull your tooth. It's sign this form that we discussed everything on the form. I answered all your questions. You understand pros and cons and things like that.

And that's what the documentation is supposed to be for. So the high tech waivers are the same thing is if you just say, Hey, patient sign this and we can bill you full fee. I don't know how many patients you can get to do it that way, but at the same time the patient has no reason not to try to revoke it later to try to get less money, or try to some of their money back.

That's the challenge a lot of people have. Versus using the form as a, hey patient, this is why you need to sign it. It's in your best interest because of reasons A, B, or C. then they won't even want to come back and try. So as an example, a lot of times insurance companies in-network, again, let's go back to the alveoloplasty thing; they don't like doing alveoloplasty on the same day of extractions. Or another one that's fun is they don't like allowing dentists to bill for frenectomies on the same day as any other surgical procedure. Well, I just tell the patient, Hey, look, your insurance company is requiring you to take off work twice, be numb twice, and go through two surgical procedures, and have to go through post op and healing and pain twice.

Does that sound like a good plan to you, patient? The patient's going to go, well heck no, can you do this together? So I tell the patient, clinically, sure, we can absolutely do this together. But in order to do that, we need to get your insurance out of the picture. And therefore, that's why you're signing this form.

And so that's a much different conversation with the patient. Oh, and by the way, patient, your insurance company is not going to pay for this service anyway, so it's not like signing the form even, is any different on the money thing, one way or the other. So you've just got to look at that and go, is the patient getting any kind of benefit from it? And that's what you should present the patient with.

Host: Yeah, that is a really good information. It's not just that they sign it, but they've got to understand it as well. And if you lay it out, certain things like you were just describing in terms that they understand, it seems to always be helpful. So when it comes to refund demands, is there a way to contest those?

Travis Campbell, DDS: So that's a great question. Of course, we all love getting refund demands because usually they happen, months or years later. And, they're probably one of the most annoying things we deal with. The question on that though is what was the reason for the demand in the first place? So you've got to look back at that.

Now, if the reason for the demand was the service should not have been covered, well, probably it wouldn't have been covered in the first place, but that's one, and there's really nothing we can do about that. You know, if it's a frequency limit or something like that, we just have to deal with it.

The one that comes up most often, though, is when your employee or patient who was an employee was terminated before they got their treatment done. And unlike medical where most people, if they have medical insurance, you know, and they were employed on the first day of the month, they are covered by that insurance until the last day of the month.

Dental doesn't tend to work like that. Dental, it's your, you're covered with your dental insurance until the day after your termination. The day you're terminated is the day your policy ends. And the challenge is, we can call the insurance company even same day and verify, and the insurance company doesn't even know that that patient had lost their job.

They only find out weeks or months later when the employer tells them, and then they take months to, weeks or months to process that. And then they come back in weeks or months to audit it, and then you get the letter from the insurance company saying, we need our money back. The best way to stop this, is prevention.

So it's talking to your patients, finding out just a little bit about them. Hey, how's their life going? How's their job going? And if the patient tells you that they lost their job yesterday, then that should give you the heads up. Oh, we need to bill this patient in full today. Now, if you want to still give them the in-network discount, great, do it.

But don't expect insurance to not want to come back and get their money later. So what you would do is bill the patient today in full. Send the claim, and I'm assuming we're in-network because otherwise out of network, it's not a problem. Send the claim and then have assignment of benefits sent to the patient and not to the office.

Because the thing that irritates us a lot is insurance can only follow where the money went. So if the money came to the office, even though technically it's to pay a patient's bill, the insurance company has to go after the money where they sent it, which is the office. But if we assign benefits to the patient, then the insurance company has to go after the patient to get that money, not us.

And now we're out of the picture and we prevented the refund problem. 

Host: So, the best way to handle this is through discovery up front, like you said, have a discussion, understand where that person is, and then, if necessary, bill up front.

How about EOBs and written write offs? Are those always correct?

Travis Campbell, DDS: Oh, you just ask your front team if they ever see errors in EOBs. I ask that question a lot when I'm doing seminars. It's fun. Cause when I have team members, they're all like raising their hands going, yeah, we saw one yesterday or more than one yesterday. So EOBs are wrong all the time. The thing people need to understand is that EOBs are not perfect.

Computer systems are not perfect. They're only as good as the human who wrote the program. And a lot of times, those EOBs are in violation of state laws, federal laws, they're in violation of contract, or they're just misinterpreted. I mean, I have all sorts of, you know, people send me claims and ask me questions all the times.

And a lot of times it's a misinterpretation of the EOB. Downgrades are a good example. A lot of times I get claims brought in where it's a downgraded service. And that doesn't mean that the dentist is getting paid less, but the EOB may be unclear about what the patient should be paying.

And so if you're an in-network provider, then you are beholden to the in-network fee for the service you provided, not for the service insurance decided to pay on. And a lot of times EOBs can be misleading or purely incorrect about that. So the important part is to understand what you signed exactly and what rules are there and are not there.

And this is kind of the fun stuff I have to deal with all the time is just educating people on, what did you actually sign up with? Don't make mistakes that are very common. And EOBs are wrong all the time. I would say it's almost a question of how many times per hour we see an incorrect EOB as opposed to is it even possible?

Host: Right. Well, that is great information. Dr. Campbell, this has been really informative. Thank you so much for your time. As we wrap up, any final thoughts from you on understanding the insurance game?

Travis Campbell, DDS: I understand insurance frustrates lots of people. I mean, that's actually kind of why I got into this insurance thing in the first place is it frustrated me so much, I had to research and learn more about it and figure out better answers. But to realize there's lots of myths out there.

There's lots of people spouting things that have no source information. And so my suggestion is to go actually read your contract. Go look at your state laws. There's a lot in there that you can learn about, that can save you a ton of money or allow you to bill a lot more money than you're billing now for the same exact services you're already doing.

And so that's the kind of fun part is, while insurance is annoying, it's also a lot of times how we get paid. I don't know about you, dentistry is pretty hard. Surgery's not easy either. And so it's, we should get adequately reimbursed for what we're doing. And a lot of times we're the challenge because we just don't know what we can and cannot do. And so my suggestion to most is just go learn more.

Host: Yeah, well said, and as you said, the more we learn and know, the more we can maximize reimbursements. Dr. Campbell, this has been really informative. Thank you so much for your time.

Travis Campbell, DDS: My pleasure, Bill. It was great talking to you.

Host: And once again, that's Dr. Travis Campbell, and AAOMS offers practice resources to help its members navigate coding and reimbursement issues. Just visit aaoms.org/practice-resources for more information. And if you enjoyed this podcast, please share it on your social media and make sure you subscribe so you don't miss an episode. Thanks for listening.