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Hot topic: preventing inappropriate dental billing consequences - what many dental practices don't know

Prevent inappropriate dental billing and safeguard your dental practice from audits and potential legal consequences

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In the world of dental practice management, one of the most critical areas that require constant vigilance is billing. The topic of inappropriate billing, often misunderstood and underestimated, can have significant repercussions for dental practices. We recently discussed this in a podcast episode, to help dental professionals navigate the complexities of billing correctly. 

Understanding Inappropriate Billing

Inappropriate billing can range from inadvertent mistakes to deliberate misrepresentations. Many dental practitioners may not even realize they are engaging in inappropriate billing practices until it is too late. The ramifications can be severe, including audits, repayments to insurance companies, or even legal consequences. Therefore, it is essential to have an open conversation about these issues to help prevent such situations.

The Legal Nature of Claim Forms

Accurately completing claim forms is non-negotiable. A claim form is a legal document submitted to an insurance company, bearing the signature of the submitting party. This means every detail on the form must be accurate and truthful. Common mistakes include incorrect listing of the treating provider. 

For example, in practices with multiple dentists, sometimes the billing provider's details are used instead of the actual treating dentist due to credentialing issues. This can happen when new doctors are not yet credentialed, and in the interim, practices use the credentials of another dentist. However, this practice is legally indefensible. The treating provider listed on the claim must always be the dentist who actually provided the treatment, regardless of credentialing status or fee schedules.

Credentialing: A Preventive Measure

One way to avoid credentialing-related inappropriate billing is to start the credentialing process well in advance. This proactive approach ensures that by the time a new dentist starts, they are already credentialed, thereby avoiding the need to use another dentist’s credentials. If credentialing cannot be completed in time, it is still crucial to list the correct treating provider, even if the claim is processed as out-of-network. In another recent podcast, Shelley DeGroff, CEO of PPO Advisors, emphasizes the importance of expert assistance in this area as there are many unknowns to navigate. 

Temporary Providers and Locum Tenens

Another frequent issue arises with temporary providers or locum tenens, as defined here by the ADA. When a temporary dentist steps in, such as during a maternity leave, it is essential to coordinate with the insurance company in advance. Failure to do so correctly can lead to inappropriate billing. If you do not, or could not complete the locum tenens process in advance, you must not exclude these providers from claims forms. Temporary providers must be correctly documented on claim forms, and any deviation from this can lead to discrepancies in clinical notes and billing records, triggering audits and potential repayments to insurance companies at a minimum. Legal issues could arise as well. If you have an emergent situation and are unsure how to proceed - contact insurance companies that you are in network with right away and ask how you should proceed, as this can vary by state and insurance provider/plan. If you are out of network - you should still contact any insurance companies you will submit claims to an inquire about the appropriate process to ensure the temporary provider is on file with them, and the claims will process.

Proper Documentation and Posting

Properly documenting and posting Explanation of Benefits (EOBs) is another critical aspect. Whoever is responsible for posting EOBs must understand the nuances of these documents. It is not just about entering amounts into the ledger; it involves understanding why certain amounts were paid or not paid. This knowledge helps avoid errors such as incorrect, or “violation of network contract adjustments” that can lead to inappropriate billing practices.

For instance, the misclassification of treatment codes is a common error. If a practice performs specific treatments like a panoramic X-ray and bitewings, these must be billed separately as they were performed, not bundled together under a different code such as the full mouth series code. Accurate billing of what was performed, rather than what might yield better coverage, is essential.

Educating Your Team

Educating your team about the correct billing procedures is vital. This includes understanding the importance of billing what is actually done and ensuring that all team members are familiar with the latest coding books and regulations. Regular training and updates can help avoid inadvertent errors that could lead to inappropriate billing.

The Role of Insurance Companies

Insurance companies are becoming increasingly vigilant. As Shelley DeGroff mentioned in our podcast, some companies even use Google to check the number of providers in a practice per the practice website compared to the claims being submitted. This underscores the importance of transparency and accuracy in all billing practices.

Take Action: Prevent Inappropriate Billing

To sum up, avoiding inappropriate billing requires diligence, education, and sometimes expert assistance. Start by ensuring all claim forms are accurate and reflect the actual treating provider. Begin the credentialing process early for new providers and correctly document temporary providers. Educate your team and stay informed about changes in billing practices and insurance requirements.

Together, we can prevent the pitfalls of inappropriate billing and maintain the integrity and trust of our dental practices. Stay informed, stay diligent, and don’t hesitate to seek expert advice when needed.

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