Billing Begins With The Back Office

Clinical notes shouldn’t stand between your practice and a paid claim. In this webinar, our experts shared how stronger documentation leads to stronger collections — and how your team can get there.

Key Takeaways:

• Why SOAP notes are essential for supporting claims
• The most common clinical documentation mistakes (and how to fix them fast)
• What great notes look like vs. what insurers reject
• Tools and workflows to make better notes second nature
• Insights from a live Q&A with billing experts

Watch the recording now to start turning strong care into stronger claims.

Want to dive deeper? Download our free Clinical Notes eBook for even more tips, examples, and tools to level up your documentation.

Why are SOAP notes so important for SRP claims?

Insurance companies often request clinical notes for Scaling and Root Planning (SRP) claims. What they are really looking for is evidence supporting the necessity of treatment. A strong SOAP note provides that documentation. For SRPs, the Subjective and Objective sections record the patient’s symptoms and clinical findings, such as bleeding, inflammation, and deep pocketing. The Assessment identifies the diagnosis, like periodontal disease, and the Plan outlines the recommended treatment.

How can we address resistance from the back office to updating clinical notes?

Resistance to changes in clinical documentation is often due to a lack of understanding about why the changes matter or concerns about added workload.

To overcome this:

1. Connect the Change to Outcomes – Explain how missing documentation can lead to denied claims, delayed payments, and patient dissatisfaction.
2. Show Real-World Impact – Share examples of denied claims caused by incomplete notes and the resulting rework.
3. Provide Tools – Offer templates, scripts, or workflows to make capturing new information easier.‍
4. Promote Team Alignment – Reinforce that documentation is part of a team-wide effort to ensure revenue and patient care are protected.

Who is responsible for completing SOAP notes?

The provider who performed the treatment—whether hygienist or dentist—should complete the SOAP note, as it is a clinical record tied to their care. However, creating complete documentation is a team effort, and everyone should contribute.

Each department plays a role:

• Front desk staff can begin by capturing medical history and chief complaints.
• Assistants can note observations during visits to support the Objective section.
• Hygienists should document patient complaints, periodontal findings, and referrals.
• Dentists are responsible for the Assessment and Plan, which include diagnoses and treatment recommendations.
• Billing and administrative staff should review notes for completeness and ensure they are properly attached to claims or prior authorizations.
  

This team-based approach ensures documentation is thorough, timely, and ready for submission.

Why are SRP reimbursements so low even with detailed notes?

There are several possible reasons why SRP reimbursement remains low despite thorough documentation:

1. Insurance Coverage Limitations – Some plans impose annual or lifetime limits on SRP coverage or require specific criteria before approval.
2. Coding Issues – Verify that the correct CDT codes are being used and match the documented quadrants treated.
3. Missing Pre-Authorizations – Some insurers require prior authorization before approving SRP claims.
4. Clinical Criteria – Even detailed notes may be denied if they do not clearly demonstrate medical necessity, such as pocket depths, bleeding on probing, or attachment loss.
5. Submission Issues – Ensure that SOAP notes and supporting documents are attached correctly and are legible.

If low reimbursement is due to contracted fee schedules, consider reviewing fee schedules and contracts with insurers. Negotiation may be possible, or practices may need to analyze payer mixes to determine the financial impact.

Do insurance companies closely review clinical notes?

Yes. While routine procedures such as cleanings and X-rays may be processed automatically, more complex claims are often flagged for manual review. During utilization review, clinical notes are scrutinized to determine if treatment was necessary and should be covered.

Missing details or inadequate documentation can result in delayed payments or claim denials. Each resubmission can add days to the payment timeline, making strong initial documentation critical.

Are abbreviations acceptable in clinical notes?

Abbreviations can save time and standardize documentation when used carefully and consistently.

Best practices for using abbreviations:

• Use commonly recognized terms such as SRP, FMX, PA, BWX, and RCT.
• Maintain a standardized abbreviation guide for your office.
• Ensure that even with abbreviations, the clinical story remains clear and complete.

Avoid practice-specific or obscure abbreviations that may confuse insurance reviewers. Overuse or inconsistent use of abbreviations can compromise clarity and delay claims.