Bill Klaproth (Host): This is AAOMS On the Go. I'm Bill Klaproth. And today, I'm joined by Terri Bradley, an experienced practice management consultant and the founder of OMS Powerhouse Consulting. Terri has worked with OMS practices across the country to improve workflows, enhance documentation accuracy, and minimize claim denials. She's here to share patterns she sees, pitfalls and practices you can avoid, and strategies that make the biggest impact before claims are submitted. Terri, welcome.

Terri Bradley: Thank you, Bill. Thank you so much for having me. I'm excited to be here today.

Host: Yes, I'm excited to talk with you about this, and thank you again for your time. We appreciate it. So, to start off, can you tell us a little bit about your background and the work you've done with the oral and maxillofacial surgery practices?

Terri Bradley: Sure. So before I started consulting in 2008 – so that's been a bit – I spent more than 20 years working in an oral and maxillofacial surgery practice. And during that time, I worked multiple roles: front desk, billing, and eventually practice management. That experience really gave me an appreciation for every single step along the way for our patient encounters and how it impacts the accounts receivable cycle.

And what I learned early on is that every step in the process is interconnected. Something goes wrong at the front desk or in documentation, it's almost always going to show up later in the billing cycle, which we don't always think about that. As a consultant, I've been able to bring that operational perspective to the practices I work with. I spend a lot of time with them – teaching teams and working directly with practices across the country to help them be more efficient, to capture the information that they need, and to understand how all of these workflows are so interconnected.

Certainly, I've been doing this a long time, and the insurance landscape is consistently changing, and working with all of these practices helps me to keep my hand in it, so to say. So, I hear about things almost as they're happening, which makes it better for all of my clients because I'm able to share information. Every week, I am still learning something new after all these years. My goal is to share what information I have with teams and practices to make their lives a little bit easier.

Host: So Terri, you've seen it all. As you said, you've had multiple roles. You understand every step the patient encounters. So you really have a great background for this. So from what you've seen working with different practices, where do claim denials usually start? Is it more on the documentation side, coding, or something earlier in the process?

Terri Bradley: You know, certainly claim denials can be any of those things that you just mentioned, Bill. But one of the things that I do see quite often is claims denials are actually starting at our first touch with the patient or with our data entry or practices not understanding or getting the information from the specific carriers about their individual guidelines.

Denials on the medical side, the most common issues I see is practices not using appropriate modifiers, not understanding the importance of a diagnosis code, and also not understanding the nuances of medical billing, such as the global surgical packages and how all of that plays out.

On the dental side, denials often occur when practices are not familiar with coverage limitations for specific procedures, such as anesthesia coverage in relationships to extractions or a plan may have something called a missing tooth clause, which could impact whether or not an implant is going to be covered or not. And practices really need to stay up on that.

But one of the most effective ways I've seen to prevent many of these denials is to have a strong claim scrubbing process before submission. And what I mean by that, there's so many offices and – I hate to say – so many doctors think that literally you just push a button and that claim goes out and all is good. But there's a lot of work that should be done before that button is pushed and that claim is submitted. And that's where we start at maybe the front desk or some other processes within the office.

Claim submission, I think about that a practice should really be verifying the patient's demographic information. Do we have their name spelled correctly? Are we using their legal name that the insurance company has? Do we have the patient's date of birth listed? Do we have the correct insurance plan chosen within our software? Do we have the ID correctly?

And then we go into the documentation. Before we submit that claim, we really need to do a stop and make sure that the documentation that the provider has given to us matches what we're billing out on that claim form. That has to match. And whether or not narratives, radiographs or additional information is required for that claim to be processed, and again, knowing our coverage limitations, such as anesthesia guidelines and missing tooth guides.

Host: That's really interesting, Terri. I think you call it a claims scrubbing position. Was that right?

Terri Bradley: It is. It's a claim scrubbing process. yes.

Host: So, somebody to look over the claim, scrub it, make sure everything is filled out properly before submission. Would that be right?

Terri Bradley: That is right. And even though, you know, some practices say, "Oh gosh, that takes so much time. It's going to take so much extra work." It takes less time to do it at the beginning than it does to send that claim and find out maybe 30, 60 days later it never made it to the carrier because we had the wrong ID number, or we didn't have the patient's date of birth correctly, or it needed more information, so now the carrier’s going to come back and ask you for it. It may be 30, 45 days later you're waiting for your money and you're sending information again. So, the more we can do upfront, the more success you will have in your claim cycle process.

Host: That is a great tip. Okay. So, we're looking for more tips for anyone listening right now who want to start improving their practices today. Can you share a few simple steps they can follow to strengthen their denial prevention strategies?

Terri Bradley: Sure. So, number one, I would start with a consistent claim scrubbing process. Particularly focus on patient demographics. Small errors in this area can stop claims from even reaching the payer. Making sure we do have the correct payer ID, and information is there. So our practice management software does a pretty good job of doing an initial scrub for us, meaning they don't let claims leave the system electronically unless date of birth, name, carrier, some of that information is there.

So we need to make sure that our offices are actually looking at those claims rejections reports. I have so many offices that don't run those reports and don't look at it and assume that because they hit the button, the claim went out the door. And the claim maybe never made it to the payer because there was something on that claim that was wrong. So we want to make sure we're definitely looking at those claim rejection and denial reports.

And from that, also, this is where teams or offices have the opportunity to really do some great training internally. If you're finding consistencies that claims are being rejected for demographic errors, well then you know you need to go back to the front desk and do a little bit of training there. If claims are being rejected because we're not sending the appropriate of narratives or attachments, we need to be doing training there. Any time claims are being rejected from leaving your system, not able to leave your system and not getting to the carrier, that's an internal process that we can tighten up, we can train on, so the practice as a whole will have more success.

Certainly make sure you're reviewing the payer submission guidelines. Each carrier wants their own special things or sometimes claims submitted in a certain way. And certainly if you are in-network with a carrier, you need to make sure you are doing that. And again, if you are billing medical insurance carriers, we want to make sure that diagnosis code that we have listed is accurate and specific. We want to make sure any required modifiers are listed, otherwise your claim's not going to pay. And these small processes can significantly reduce your denials across the board.

Host: Terri, that is great information. I love doing this podcast because people just go ahead and rewind. If you weren't able to take notes, rewind, and go ahead and grab all that stuff that Terri just said. That was really great, Terri. So, thank you. I'm just curious, I know you've seen it all, and we love getting real-world examples. Can you share an example from your experience, perhaps a time where a small change made a big difference in reducing denials?

Terri Bradley: Absolutely. I'm happy to share one. So, this is from a practice that brought me in for consultation because their accounts receivable was going through the roof. Their numbers were trending in the wrong direction and they were at a loss as to how to fix this and what to do with it.

And when I sat down and met with the team, what we found was that there was a culture of, "This is my job, this is your job." And the insurance information or the information relating to billing was staying within the billing team. But a lot of the denials and a lot of the reasons that these claims were being denied was because at the front desk, the demographic information was not being input correctly. The team at the front desk didn't understand the “why” behind all of the different fields that they needed to complete. So, why was relationship to subscriber so important? Why or how do we choose the correct carrier?

And when we spent some time with the front team, not blaming, but actually teaching and explaining how one little box can impact the whole claim cycle, things turned around really quickly. In this particular practice, there was a lot of finger-pointing rather than embracing and being collaborative.

What we did also with this team was we created a metrics box where we tracked who was missing date of birth, who was giving us the wrong ID number. All of those things that can cause a claim to deny, we started tracking it by office and by employee so we could target our training to the people that needed it, rather than just sending out this blanket email, "Make sure you do this, make sure you do that." Because people want to do a good job. People want to do what they should be doing. And after teaching the team members the “why” behind it and showing them the specifics, this practice's AR turned around.

Host: Yeah. This is like a blueprint on how to get everybody pushing in the same direction on the same page. What a great example. So thank you for sharing that, Terri. And that really does illustrate exactly what you're talking about, and I imagine maintaining consistency among practice staff can be difficult at times. I go to a dentist, and sometimes there are different people there. Turnover is normal, let's face it. So from your perspective, what helps teams stay on the same page and avoid the kind of mistakes that lead to denials?

Terri Bradley: Sure. So, one of the things is just being consistent, having consistent claim scrubbing processes and tracking where the errors are occurring and why, so we can nip those in the bud. But that also becomes a training opportunity, and again, embracing everyone and making sure people understand the whys behind it.

Preventing denials really is a team approach. And again, I'm going to go back to insurance knowledge in an office. It is my firm belief that the people that answer your phone have got to have an understanding about insurance, whether it's going medical or dental, how your office handles being in or out of network.

The people who are doing the data entry have to understand the importance of that. The providers have to do a really good job with their documentation so that when we do have a denial, I have the support and the documentation to appeal if there a denial is there.

The treatment coordinators. Treatment coordinators are the people I have in the office that take maybe an insurance verification. We've contacted an insurance company and found out what benefits a patient has, and we put that puzzle piece together with the treatment plan that the provider gave after meeting with that patient, and now sits down with that patient and explains their out-of-pocket, what insurance may or may not cover. So, treatment coordinators understanding the nuances of each of the carriers and their own specific guidelines is key. And having the billing department then review and scrub all of that information prior to submission.

Communication is key in any office. I think a lot of teams say, "Oh, we need better communication. We need to be better at sharing information." I think for the claims processing cycle, I prefer meetings followed up by emails so that I have certainty that people understand what I'm saying and what I'm sharing.

Also, make sure that, when the billing department does start to see denials, that we're sharing that information with the people at the front desk so that the front desk is able to educate our patients. The treatment coordinator is aware. We all need to share in this whole revenue cycle – especially with insurance carriers – because, as I mentioned, the landscape is changing all the time. All the time.

Our codes change annually – CDT, CPT. And I just have to say, someone in the practice has got to stay up to date with coding updates and insurance industry changes. It is key. And my go-to place for that is AAOMS. AAOMS is an excellent resource for coding guidance, updates, and education. They have so much education available for staff. And having a designated team member responsible for monitoring those changes can help the entire practice stay compliant and avoid preventable denials. But this person who's responsible for monitoring those changes has to be able to share them with everyone in the office who needs to know it.

In my opinion, it is everybody in the office that needs to know it. It's not only front desk insurance verification, but it's the providers and the clinical team too, because we're all in this together.

Host: Yeah, I love how you said this is a team approach. And to me, that really sums it up. It's not just on one person. It sounds like everybody has a role to play in this. So when you say this is a team approach and communication is key, that really makes sense.

Terri Bradley: It's totally a team approach. This is not one person's problem.

Host: Right. Absolutely. Terri, thank you so much for offering a clear and a practical look at denial prevention in OMS practices. This has really been great, a lot of wonderful information. Thank you again for your time.

Terri Bradley: Thank you so much for having me. It was my pleasure.

Host: You bet. And once again, that is Terri Bradley. And as Terri said, AAOMS provides a comprehensive suite of coding reimbursement tools, including online coding courses, webinars, and additional resources to support practice success.

To learn more, just visit AAOMS.org/Coding. Once again, AAOMS.org/Coding. All the good stuff that Terri was just talking about.

And if you enjoyed this podcast, please share it on your social channels and make sure you subscribe so you don't miss an episode on dental advocacy, leadership, and the future of oral health care. That's what we talk about on this podcast.

I'm Bill Klaproth. This is AAOMS On the Go. Thanks for listening.