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The most important aspect of Medical Billing for Dental Procedures is the Dental Professional’s documentation thought process. It is important to document the “Medical Reasons” behind the required dental treatment; and also, the health consequences if the dental condition is not treated.
Is there an overlap of what procedures should be billed for medical or dental insurance?A “dental practice” can bill to the “Medical Insurance Provider”, but to get paid for the claim, you must first understand the nuances of “Medical Billing For Dental Procedures”.When billing to medical insurance, it is important to remember that “Medical Insurances” do not focus on what the patient needs, they need to know “why the patient needs the treatment!” This entails changing the clinician’s thought process to consider not just what needs to be fixed, but how did the patient get that way? (“The Medical Necessity.”)The following are some of the medical reasons for dental treatment:
Inflammation and infections not treatable by entry through the tooth;Hard and soft tissue pathology such as biopsy or excision of hard or soft tissue lesions or surgical placement of implants;Certain types of dysfunction such as skeletal dysplasia, sleep apnea, oral dysfunction;Anything and everything related to traumatic injury. This can include implant placements, removable and fixed prosthodontic, restorative treatment, endodontic, and surgical treatment. Periodontal treatments can include sinus elevation and osseous surgery. Orthodontists can consider night guards and palatal expanders for skeletal anomalies as medical treatments.HMS’s Medical Insurance expert billers will help dental practices obtain maximum reimbursements from patients’ Medical Insurance. Important points in Medical billing:
1. The Dentist must include in addition to the SOAP Clinical Evaluation and all other diagnostic procedures, the following notes:Proper treatment explanation;Length of the treatment;Specific area of the mouth where treatment will be done ( eg. Gum, tooth, upper jaw );Primary care physician information of the patient medical insurance;When was the last time patient visited his or her Primary Care Physician; since we need a referral letter from the PCP provider of the patient to obtain approval;Clear x-rays of the patient current condition and other supportive documents from Medical History.Medical billing requires diagnostic codes to support medical necessity of procedure codes to be submitted with the claim;3. Insurance coverage depends on an exact match of plan coverage and diagnostic codes for procedure codes;4. All information should be correct to get paid by the Medical Insurance, e.g. patient, provider, and insurance demographics, diagnostic codes and procedure codes, modifiers, narrative submission, etc.5. The Dental practice has to call up the Medical Insurance of the patient to find out whether they will cover Dental Benefits. In other words, if they cover Dental procedure which are medically necessary.6. Pre-Authorization is mandatory before billing to Medical insurance.7. Medical claim submission has 90 days from date of service prior to expiration.8. Almost every time, Medical Insurances reimbursements are significantly more than Dental Insurance payments.HMS can assist your dental practice in getting paid from Medical Insurance Providers:
HMS will provide the Dental Practice with the list of services that are covered by Medical Insurances, so that Dental Providers become aware about them, before the patient’s visit;Our team will call up the Medical Insurance company to find out if they cover Dental Benefits, and make sure they will accept the claim;Based on the practice’s notes from the Dentist, our team will prepare a pre-authorization, and we will submit it to the Medical Insurance for approval;Once we receive the pre-authorization number from the Medical insurance, we will bill the “Medical” insurance with the appropriate “diagnostic codes” and CPT codes to have the claim paid.Out team will follow-up with the patient’s Medical insurance, after 10 days of the claim having been submitted, to find out how much the Medical Insurance Company has paid.Once the practice receives payments, the dental practice or we can post the EOB information in the Practice’s Management Software.Reimbursement from Medical insurances is a minimum $1000 in most of the cases, based on the treatment.Medical and dental billing shares the following:
Patient and insurance information has to be obtained, verified, and correctly set-up in the Practice Management System;Procedures must be coded and fees established;A claim form is submitted;Payment is received with and explanation of benefits (EOB) that needs to be broken down in the Practice Management System;Claims need to be followed until payment are received and re-submission and appeals are performed until payment are obtained;Patient’s portion must be collected after the insurance claims are resolved, or must be collected prior to the procedure (if an estimate of patient’s portion is possible).Differences between Medical Billing and Dental Billing:
Medical billing requires diagnostic codes to support medical necessity of procedure codes to be submitted with the claim; there are no requirements yet for diagnostic codes in dental billing, however, diagnostic reasons for dental procedures are provided upon request by the Medical Insurance, during narrative submission with claims, and during claims appeal process, and must be documented in the patient’s chart.Insurance coverage depends on an exact match of plan coverage and diagnostic codes for procedure codes. Claim denial is more likely with medical claims, due to the requirements necessary for a “clean” claim submission; therefore, it is important to find out information requirements for certain procedures, during the coverage verification process (pre-certification and pre-authorization) before the claim is submitted.Sending “clean” claims in Medical Billing is crucial to obtaining coverage and payment. All information must be accurate including patient, provider, and insurance demographics, diagnostic codes and procedure codes, modifiers, narrative submission, etc..Pre-certifications (“pre-certs”) for treatment are important prior to proceeding with treatment. Decisions are made, once pre-certs or denials are obtained from the Medical Insurance, to submit to “dental insurance” instead. The patient can make a decision whether or not to proceed with treatment, based on the information received from the pre-certs. Other pertinent information is discovered during the pre-cert step that aids in claim submission and claim coverage based on the information disclosed in the pre-cert. The insurance company will determine whether the procedure needs to be pre-certified or pre-authorized.Pre-certifications establish that the procedure “MAY BE” medically necessary and needs a review prior to payment.Pre-authorizations establish that the procedure “will be covered”, but the insurance company does not disclose any fees.ADA codes for dental treatment encompass many procedures that are not coded, but are part of the fee (ex: lab materials, lab fee, temporary crown fabrication, visit for insert of the crown, x-ray when crown was seated etc.) Those parts of the treatment are included in one crown fee. In medical billing there is a service CPT (reports medical, surgical, & diagnostic procedures and services) or HCPCS code (products, supplies, & services not included in the CPT codes) for all the parts of treatment or a procedure which would add up to the analogous one fee in dental coding. The fee for medical treatment is obtained from coding all parts of the treatment. Dental billing bills for a “product” provided and this product has one fee that is coded. In Medical Billing, we bill for treatment of a “condition” provided (includes services performed based on time and complexity, products/devices, materials used and amounts, and diagnostics procedures, the procedure can be broken into technical service and professional service provided).>Medical claims submission has 90 days from day of service prior to expiration, while dental insurances allow up to 6 months, or even up to 1 year, for claim submission from date of service. Therefore, if the “Medical Insurance” does not pay for the dental procedure, there is time to submit the claim to the Dental Insurance provider. The claim cannot, ethically, be submitted simultaneously to the Dental and Medical Insurance. If you submit $500 to the Medical Insurance for a procedure, that gets denied, you have to submit $500 to Dental Insurance for the same procedure. This is why, the price for the procedure, billed to Dental or Medical Insurance, has to be the same. Several medical codes (which will include services, products/devices, materials, and diagnostic procedures) may need to be used for the analogous ADA code, but the price for the treatment should be the same. Many ADA codes include procedures that in medical coding are billed separately. Ex: x-rays in dental billing include the diagnosis and reporting, while x-rays in medical can be billed as a service fee (technical component) and the reporting fee (professional component) with a modifier 26.Narratives/letters to support “Medical Necessity” are crucial to obtaining medical claim coverage; in dental billing, letters of medical necessity are only necessary for ADA codes that ask for narratives by report or during the appeal process, or as a follow-up to referring provider.Medical reimbursement for exams/practice visits/consultations depends on time spent with the patient’s encounters, complexity of the encounter/exam, and reimbursements for each encounter for previously diagnosed condition, in dental follow-up visits and visits for previously diagnosed condition are considered part of the dental procedure.Medical insurances do not provide fees for treatment during the benefits verification process, or pre-certification process, but rather, informs if treatment is eligible for medical billing after claim examiner review. The Pre-authorization will tell you if it will be covered by the Medical Insurance plan but the insurance company will not disclose the fees. The reimbursement depends on the medical plan’s reimbursement schedule, covered benefit, and if it is a medically billable procedure. It is not possible to do a sound pre-estimate and figure out the patient’s responsibility for the treatment. Therefore, the Dental Provider or Dental Administrator must decide how much will be collected from the patient at time of service. If the Medical Insurance reports that the dental services will be covered (pre-authorized) and can be submitted, it is recommended that a minimum of 1/3 should be collected from the patient, as a down payment at the time of service. Some Medical Insurances are known to take a long time to pay out. Therefore, some dental providers might consider to collect the total amount from the patient, at time services are rendered, and then send insurance payment to the patient directly when the payment is received.Most Medical insurance have higher reimbursements for dental services, than dental insurances resulting in a lower patient balance, and therefore, it increases the ability for patients to obtain recommended dental services. This happens because several parts of one dental code are billable to Medical insurances resulting in payments for several more codes yielding higher insurance reimbursement. In addition, Medical insurances do not have clear provisions or historical payments on dental procedures; consequently, often Medical insurance companies, pays well on those codes resulting in higher reimbursements.Dental insurance allows to charge out indirect procedures, involving a laboratory, on the day of impressions, while indirect procedures can only be billed out to Medical insurance providers, the day you insert the prosthesis.How to get started? The Dentist must decide which procedures they will perform, be eligible for medical billing.The Dentist has to make a Medical connection based on the Medical history to the dental treatment that needs to be provided. A letter of “Medical Necessity” needs to be written and submitted with the claim. (HMS has provided the Medical form for Dental Providers to use.)3. Next, we suggest the Dentist runs a report of those medically-billable procedures that were already treatment-planned, from the practice management software. Call the patients and obtain their Medical insurance information. Inform the patients that you will attempt to check with their Medical insurance for assistance with their dental treatment plan reimbursement. You only schedule the patient when there is pre-certification, pre-authorization. When calling the patient to schedule, make sure that at least 1/3 of the fee is discussed to be collected at time of service towards the treatment plan before pre-authorizations. Also, discuss the full fee for the total treatment plan, before it is submitted for pre-certifications, in the event that the Medical insurance does not pay at all. Have a “back-up plan” to submit to the Dental insurance and quote the patient the Dental insurance breakdown based on dental insurance coverage history; in this case make sure to disclose the patients’ portion, deductibles, co-payments and/or credit lending arrangements.Let Health Management Solutions, Inc., assist you to implement Medical Billing for Dental Procedures in your dental practice, please give us a call.
Why only us?1. HMS has teamed up with an Associate Billing Provider who has a Certified Team of Experienced Medical Coders; they will ensure that your dental practice will get paid on every approved pre-authorization.2. HMS has teamed up with an Associate Provider who has an experienced billing team and know how to communicate with Medical Insurances Providers to verify dental benefits, and also collect payment and submit additional information if required by the Medical insurance carriers.3. HMS takes this cumbersome and tedious process of dealing with Medical insurances providers, and our experience professional billing team will get your practice reimbursed within approximately 20 days of a claim that has been submitted for payment to the Medical insurance company.DentalMax is a completely integrated, turnkey dental practice management solution.
Web enabled in nature, and available in real time, DentalMax offers Clinical Records, it offers Facilities Management, it offers Payment Management, and it also offers a robust Back Office operation enabling Billing, Accounting and Financial Reporting.
Available through a simple internet connection on just about any internet ready device, no special equipment is ever required, it directly integrates with your present X-Ray system, there’s no further need for system back-ups, there’s no longer a need for merchant accounts or credit card terminals, there’s no more loss of data due to power outages or other irregularities, there’s no more patient data stored on local computers, there are no more HIPPA nor OSHA violations.
DentalMax is without a doubt, the ultimate path to a successful, compliant, automated practice.
Here are some of the Clinical Records highlights:
Here are some of the Facilities Management highlights:
Here are some of the Payment Management highlights:
Here are some of the Accounting and Financial Reporting highlights:
Insurance Payment: HMS through its’ Associates Subcontractors, will post insurance payments received in the practice’s Ledger as per the instructions of the (AR) Manager. We will collect payment information from various sources; however, the dental practice is responsible to inform HMS and its associates, about the availability of the payments and related documents via email. Those sources are:
Lock BoxSFTP (Secure File Transfer Protocol)Insurance WebsiteScanned EOBs and Checks mailed by the dental practiceAs per the guideline defined by the AR Manager, we will write-off the payment in the Ledger.
Timeline: We will follow the timeline defined by the AR Manager, to post payments because it is necessary to have a crystal clear understanding of the DOD (Date of Deposit) and the Closer time-table (usually happens at the end or beginning of the month).
Reporting: On a daily basis, we will share with the Account Receivable’s (AR) Manager the Run-Tape (spreadsheet which contains the summary report of payments). In the same report, we will also highlight payments, which were not posted due to certain discrepancies, or they require the AR manager’s immediate attention and clarification. As per the indicated time-table, we will share the Monthly Report with the AR Manager.
Credit Card payment: Following the instructions of the AR Manager, we will also post Credit Card payments which were made by patients. In order to prevent fraud and misuse of the financial data, we follow strict confidentiality and security practices, and we abide by HIPAA’s Privacy Act requirements.
We will make sure that all the patients’ documents are kept in their respective patient’s account, in the Document Center of the PMS. Such as:
1) EOB (Explanation of Dental benefits),
2) Pre-Determination,
3) Driving License,
4) HIPAA form,
5) Other Contract Agreement,
6) Dental Benefits Breakdown
These documents usually come in bulk, especially from the dental insurance end. Hence, we will split these in various manners such as by-Date, by-Patient Name, by-Insurance, etc., and will upload them in the directory of the patients’ document.BMW courseHIPAA and Florida LawHIPAA Omnibus RuleOSHA’sBloodborne Pathogen StandardOSHA’s Globally Harmonized System of ClassificationSexual Misconduct and Harassment in the Dental Practice