Sorting Out the Medical Billing Mystery

Sorting Out the Medical Billing Mystery

Written by Dr. Dorothy Kassab, edited by Kevin Wilson

It is quickly becoming apparent that understanding of medical billing—at least as far as it impacts the dental practice—is an essential piece of knowledge to obtain. Increasingly, there is crossover between the medical and dental insurance realms, and issues of proper coding or procedures can delay payouts. Moreover, dental insurance companies—especially the larger firms such as Aetna, Cigna, Delta Dental, and Met Life—have built requirements into their protocols that medical plans must be considered for most surgical claims. If proper procedures are not followed, claims may time out and become unrecoverable. When offices are ill equipped to handle this and don’t have a medical EOB to file with the dental claim, it will be denied and the practice will be the loser.

Anything that delays insurance payout or places more hurdles in front of the provider, thus increasing the chance for errors/denials, helps the insurance company. They know this and will do anything in their legal power to minimize the size or likelihood of payout, keeping as much money in their pockets as long as possible. Abundant resources allow them to hire legions of lawyers and insurance experts to keep it that way, leaving the other side—us—woefully lacking in that kind of support unless practices on the part of insurance companies are particularly and obviously egregious. However, in their defense there was a loophole for a while that dental providers could sometimes use to claim extra benefits by hitting up dental and medical providers simultaneously. There were not yet regulations in place to prevent this practice, it was not illegal, and there was no established protocol for refunding medical insurance due to overpayment whereas dental insurance companies have had coordination of benefits policies for those situations in place for some time.

There are also issues of cross-coding to consider. For example, take anesthesia CDT codes D9222 and D9223; these translate to CPT code 00170 for the initial 15 minutes and 00176 for each additional 15 minutes of anesthesia administered, with modifier 47 added to each line item to indicate that a surgeon (the dentist) administered the anesthesia. For CPT code 41899, most insurance carriers only authorize one CPT 41899 per date of service but if you add modifier 51 it translates as multiple procedures to be completed for the service. Without trying to directly address the many issues such as these individually, there are three fundamental issues to consider in the office setting to maximize one’s chances of successfully navigating these waters and reducing time-wasting mistakes: Education/knowledge, timely filing practices, and thorough and accurate documentation.

Lack of knowledge is no excuse but is often the culprit, as new policies and their potential impact may not be immediately digested, especially in this current era post-COVID where practices may be re-establishing their footing. This has an easy solution: encourage and support continuing education for your office staff that includes understanding of the ever-evolving world of billing codes and insurance claim execution that involves medical billing. While insurance companies are required to inform all providers regarding new policies or changes to existing policies, they are not required to do so in a way that’s particularly helpful to you and your staff. Show your team that you are serious about equipping them by paying to develop their knowledge base. Invest in your staff! Nothing demonstrates your commitment better than an example, through action.

Timely filing is a simple solution to the medical-dental insurance issues surrounding insurance procedures specifically, but it is always good to file quickly so that you have more time to address problems that may arise. Generally this does not mean filing shoddily with inaccurate information when proper procedures are always the best way to save time and reduce mistakes in the long run. However, it is wise to consider that even a potentially imperfect claim submission may be necessary when billing a surgical claim with crossover, because time is a factor and getting both medical and dental claims on file will prevent timely filing failures. Dental insurance companies now require EOBs from the medical carrier in surgical cases. They know that the vast majority of the time, the medical plan won’t cover treatment, but still require providers to submit this information before they’ll pay. If too much time passes the claims may become unrecoverable—which is a possibility because your staff must submit to medical insurance as well and, once a determination is obtained, submit to dental insurance while the timely filing clock continues to tick away. Therefore, file both claims at the same time; if you don’t know the cross coding, file with ADA codes—then commit to learning what you discovered you needed, because you will likely need it again! Learn from your mistakes.

Office staff must become good friends with CMS 1500, the standard health insurance claim form. Know what supporting documentation is required, and which fields need to be filled out to get a claim on file. Immediately send any correspondence from the medical carrier to the dental carrier—most of the time it will be a denial due to coding issues, but it doesn’t matter what caused the denial, only that the dental insurance knows it’s been denied by medical insurance, because they must then proceed with review of the dental claim.

Overall, your best line of defense against problems that may arise at the nexus of medical and dental insurance is your system of well-executed office protocols promoting the diligent, thorough collection and application of documentation, consistent checks of eligibility, and learning which services require involvement of the medical carrier. The groundwork for this is laid at the front desk with complete, accurate insurance (dental and possibly medical) and demographic information obtained and confirmed regularly. Keep patient health history up to date with regular review by clinical staff before visits. Full documentation of what, when, where, why and how is incredibly important. Specifically, especially in cases where medical insurance may come into play, reason for visit is key in medical billing. Documentation paints the picture you need for both medical and dental billing and reduces errors and coding inaccuracy.?