Dental Insurance Claims: How To Get Paid For What You Do

You're listening to the Phil Klein Dental Podcast Thanks for joining us. I'm Dr. Phil Klein. Have you ever wondered what the mindset of a dental insurance claim reviewer is like? My guess is probably not. But before you click out of this episode, think about it. If you know the answer to this question, you're at a great advantage when dealing with insurance companies and getting paid for what you do. To tell us more about this is our guest, Dr. Dominique Fufidio. Dr. Fufidio is the CEO and founder and main coach at Fufidio Consulting Group, where she has pioneered a unique coaching offering, one focused on understanding the clinical aspects of the dental insurance claims review process. Before we get started, I'd like to thank our sponsor, Philips Oral Healthcare. This is a phenomenal company that helps you empower patients with innovative, evidence-based solutions that meet your patient's unique oral care needs. Philips Oral Healthcare's advanced product line features Sonicare power flossers, electric toothbrushes, and zoom whitening. To learn more, visit their dental professional website at philipsoralhealthcare.com. Dr. Fufidio, it's a pleasure to have you on the show. It's great to be here again. Thanks for having me back. Yeah, we were just talking offline before we started this podcast how busy our day is today, but we both made the time to fit this in, which is awesome. our listeners are really growing on the show. So this kind of material, this kind of content is so relevant to everybody that's in the dental business. There's no doubt about it. And that is getting paid for what you do. I mean, as much as we are healthcare providers and we love doing the best care possible, it's still a business and we have to get paid to keep everything going and pay our bills as practice owners. So given that, what does a typical day look like for a dental claim reviewer? And before you get into that, Correct me if I'm wrong, you're telling us this from the mindset of someone who was a claim reviewer in the past, correct? Yes, exactly. And what was your mindset when you were reviewing some of these insurance claims? Now, I was what was called a clinical claim reviewer. There are claim reviewers that may be uploading attachments and making sure that a claim is clean and complete and can actually have adjudication made on that claim, meaning a judgment made on it. But I was a clinical claim reviewer where I'm actually looking at the documentation, the narratives, the images that are submitted, the radiographs to make a determination. Was this treatment actually medically necessary? And you worked for an insurance company doing this? So there's a concept called utilization management where. You're looking at the codes that are being submitted and how they're being utilized in the office and in the insurance realm. And utilization review, the review of those codes that are submitted, that can be outsourced to a third party if there's not enough bodies to do it in-house or if you don't have maybe a licensed dentist in the state that's required for that specific claim. So I was contracted by a utilization review agent. Now a utilization review agent, and this is a wonderful question, I actually teach to this they cannot make the final determination on a claim saying yes or no this claim will be paid but they can make a recommendation to their client which is the insurance company saying I recommend this claim be paid or I recommend that it not be paid benefits are not recommended if in the event you recommend not to be paid does the dentist actually reach out to you? Do you have an interaction with the dental practice, whether it's the dentist or someone else in that office? So all communication does come through the insurance agent. Now, if I make a record or made a recommendation that benefits were not recommended, that would be relayed to my client. And then the client would make the final decision of, do I want to stand by my utilization review agent that's been trained on my criteria? Or do I want to say, ah, we're going to still allow this one? They usually stand by what the utilization review agent is recommending. They will send the correspondence. That's where that EOB, and we've defined that before as the explanation of benefits. that will be sent directly to the dental office, but they may contract the utilization review agent, meaning the insurance company may contract the URA, utilization review agent, to be the one to handle any communication after that. So if the dentist would like to understand more about why this claim was denied, then the utilization review agent clinical claim reviewer can call the dentist and have some interface like that. Every client is different. Some clients do not want the utilization review agent to have any contact with the office, but all the paper trail goes either through the client or if the utilization review agent is contracted to do certain forms of verbal and written communication within the state compliance that can come from the utilization review agent. An example? Yeah. So we'll get into an example in a second. So there's basically an insurance company. There's a big fat insurance company that makes lots of money. Then there's a utilization agent, a review agent, right? Underneath that. Yes. Is that part of the insurance company or is that also outsourced as a separate business? Well, I want to also say that insurance companies are not ridiculously profitable. There is a very low profit margin and there's a lot of discussion in the industry right now about that. Not every insurance company will contract a utilization review agent, but it's almost like a business associate. If you're bringing someone into your practice, they're supposed to conform to what your clinical policy and criteria is. Now, when you were saying we'll get into examples, those are examples of specific things being reviewed, but a name is sometimes helpful. PNR Dental Strategies is a utilization review agent. Fluent is a utilization review agent. And I love teaching this in my courses because I would be working with, let's say, United Concordia, and I would have a patient that had insurance through United Concordia, but then I would see written communication coming from PNR Dental Strategies saying that my claim did not meet criteria. And I remember asking the clinical claim reviewers in my peer-to-peer calls, Who are you? Is this a phishing scam of some sort? So it was explained to me then. And that's why I love a peer-to-peer call because it's a learning opportunity. Yeah, so let's talk about the peer-to-peer call. So let's say you get an adverse determination. The dentist did the work. It was denied for whatever reason. Let's say you denied it when you were a reviewer. Then it went back to the reviewing agent. And then that... sends the dental practice a letter or communication saying your services that you submitted have been denied and you decide you want to call up and find out what's going on who do you call and who is the person that represents your practice the dental practice what is that process yes understandable now when i was a clinical claim reviewer for a utilization review agent i like to be very polished in the terminology i would never make a denial i would make a recommendation that benefits were not recommended the insurance company would then be the one saying deny so the denial could be administrative there could be something that's just missing that's integral for me to actually say yes this meets all of the the check marks in the box so i always after an adverse determination recommend doing an appeal and submitting all the information you have pertinent to that specific treatment now i code on specific items that need to be included that the clinical claim reviewer is looking for and we can talk about that later specific recommendations but if you go through that appeal process and then you're saying I'm still not getting benefits for treatment that I feel is Something that warrants coverage, which I have to say insurance companies, they do want to pay out benefits. They understand that there's less friction with the provider. You're not going to lose members. They're very open to paying benefits when they're warranted. There will be some form of indication on that EOB, that explanation of benefits, saying if you would like to exercise your right to a peer-to-peer call or would have some customer service line. It could direct you to the utilization review agent like P&R Dental Strategies or Fluent or it could say go to the Department of Insurance. It could say call Guardian directly. So you would just have your front office call and say we would like to arrange a peer-to -peer call. We'd like to exercise our right to that. It is a right that you have to understand why that claim has the adverse determination. Okay, so that's the process, and we'll get into that phone call in a second. Do you tell the patient that the claim has been denied before you do all this, or do you try to reverse this and not even bring the patient in yet? I'll have to understand that question a little bit more. Are you saying so the patient is not doing the peer-to-peer call? No, no, I know that. I'm Dr. Klein. I did a root canal on John Smith, and I submitted the claim. Thing came back denied. Somebody reviewed it and said, Maybe the distal buccal root is two millimeters shorter than they like and they denied it. I don't know. Then I want to get on a peer -to-peer call and say, hey, that was a completely calcified root. I couldn't get any further than that. And based on the calcification, the prognosis of this case is excellent because you can't go any further. So do I even tell the patient that the claim was denied at all at this point or not even clue them in on that and just keep going with the attempt to get paid? Now I understand your question, and that's personal preference. I always had my office communicating with the patient saying, we understand there was an adverse determination, but Dr. Fufidio is appealing this. She will go through these measures of a certain amount of appeals, which mine was normally two to three. And then she will exercise her right to a peer-to-peer call to understand why this claim has the denial, essentially. But the patient will be getting copies of an EOB as well. And every time you resubmit, they will get another EOB. So I found it was more helpful to just keep the patient informed. But that's a matter of personal preference. Okay. Tell us about what preparation you recommend for the practice to have in hand when they have that peer-to-peer call. And is it essential for the dentist who did the work to be on that call? I am so happy you asked because as a clinical claim reviewer, where I was, and I had heard this as standard across the industry, I was instructed to not wait more than two minutes on hold because I have a certain amount of claims I have to be calling on and closing. So if I had my front office submit the request by making a call saying we'd like a peer-to-peer call, they were normally told, okay. clinical claim reviewer will call you in two business days on back-to-back days between these hours and they'll work with you on the schedule to get a loose timeframe of when they should call and that's why at the earlier part of the show I was talking about what your schedule looks like a lot of these things are dictated by office availability so i was instructed and this is largely uniform again across the industry to make a good faith attempt at calling during those hours and if the doctor was unavailable or could not make it to the phone within that certain amount of time and i flexed it because i can multitask and do a couple things but i did have regulations i had to practice under um i would call back on the following business day now my protocol was that was um given to me that if i were to call on two back-to-back days and not reach the doctor and we can talk about who we have to actually speak to that claim was closed there's no change that is to the denial and the office can call back and arrange another peer-to-peer call But we have to close these because there are statewide and federal regulations about these claims going so long without any action. you had asked does the dentist have to be involved in what preparatory work i always tried to be as prepared as possible because i wanted to get on that call be quick and efficient and frankly those claim reviewers they're not getting paid much for that time on that call so i wanted to be very efficient with the delivery of my message and just like your example of when you were going over that root canal case you were explaining something that sounds as if there could have been a a perceived poor prognosis, but then you're explaining it's not a poor prognosis, there was a calcified route. You can have that conversation, and if it's convincing enough over the phone, many times the clinical claim reviewer can say, I'm going to recommend to the insurance company that benefits are allowed, that this denial is overturned. And then there's some legwork that needs to be done on the claim reviewer side. Now, sometimes those calls sound very cookie cutter. And the clinical claim reviewer has the right to ask for convincing documentation, which would be maybe a screen capture of your clinical progress notes. And that's something I teach too, because I want to make sure that my clients know exactly what should be in their documentation so they can have a screen capture and send that along. Yeah. As a reviewer, how often did the dentist or whoever was on that peer-to-peer call reverse an adverse claim? So it depends. Many times with scaling and root planing claims, they were hard to overturn, and it was more of an educational moment where we're saying, hey, I understand that you are perceiving an area as having bone loss, but this specific insurance provider needs to have bone loss of... amount measured radiographically from the CEJ to the crest of bone. So that's their criteria where they're saying there are no benefits if we don't see a certain amount of bone loss. So those are hard to overturn. But for cracked teeth, your example of a calcified canal, sometimes we don't know that there was an endo done because the endo is done by the endodontist and maybe the pretreatment x-ray is the one prior to endo and the tooth doesn't look that bad. It looks like it could be restored with a direct restoration, but a narrative can really help overturn that adverse determination. If it gets to the point where it's a peer-to-peer call, those are very easy. Just talking through, well, walk me through what happened during that clinical procedure. So I would say I was overturning less than half. But I enjoyed my peer-to-peer calls because I was able to actually speak with the dentist and say, this is what we're looking for, which is basically what I started with the video consulting group, and let them know for future opportunities. Yeah. When I was practicing endodontics, I did have some of those calls. And I tried to be as nice as I could, but when I started to get the resistance and some of the rigorous, stringent protocol that they had in place, I would say, listen. As an endodontist, there's more than just an x-ray. If a patient has irreversible pulpitis, for example, the x-ray could look fine. There could be just some deep decay. It looks like it could be fixed with a direct restoration. But, you know, when you put cold on this tooth for three minutes, the patient's in agony. So there's a severe irreversible pulpitis going on, and that's not visible in an x-ray. So that discussion, I guess, has to be had with the reviewer. I always thought that... companies kind of made you work for it in those gray areas where it wasn't super obvious by an x -ray. They kind of wanted the practitioner to make the phone call, schedule it, get on with a reviewer, fight it out a little bit because they knew there would be some percentage of clinicians, healthcare providers that wouldn't go through that process or wouldn't be prepared to somewhat quote unquote battle it out with the reviewers. And so they wouldn't have to pay those claims. I don't know. That's how I felt. But you're saying that that's not true because from your perspective, you're saying the insurance companies actually want to pay it out. They just have guidelines that they have to follow. Let me just wrap up this podcast episode. It's been fantastic information, Dr. Fufidio. Really, really well explained on your side. The last question I have is, and we can do this in about two or three minutes. What recommendations do you have for like those tricky codes or those specific? CDT code recommendations, CDT meaning current dental terminology code recommendations. You have some recommendations for us to share. And also we want to know where we can find you for more information. I know you have a great training program, which I want to know more information about so our listeners can contact you if they want to get their office trained on some of the great stuff you have. oh so many things so to answer your specific cbt code question recommendations that is everything i teach too and it will be way too long to go into now but i'd like to focus in on just that example you were talking about because you are correct there has been a paradigm shift where insurance companies want to auto recommend auto accept a lot of procedures so in your endo example a narrative a narrative about that irreversible pulpitis would be integral and i would say not just putting it in box 35 because box 35 of the claim form which is going to be redone in 2024 i haven't seen the new claim form so i don't know how box 35 the remarks section will be impacted but adding a separate attachment saying tooth was endodontically treated because of irreversible pulpitis that will help you be successful that specific example Many insurance companies, they're not actually looking to see was the endo necessary. They want to know for a crown if an endo was done. So segueing into crowns, was there a cusp loss? Was there a decay that was so extensive that it meets, like you were just alluding to, the specific criteria for that specific insurance company? Maybe at another time I can go into what the general... criteria are across the board because it's very very similar although slightly nuanced. We talked about scaling and replanning needing to have that bone loss criteria but extractions were you actually removing bone and sectioning the tooth because of necessity or were you sectioning the tooth to facilitate a simpler type of extraction, better healing. These are the types of things that I like a dentist to think about so they can write a well-written narrative so that way you have benefits that can be allowed. And then also we talked last time about those mailroom submissions. If you remember you were talking about how there was always a delay in your claim adjudication process. Submitting electronically, those mailroom claims, they're very very hard to visualize the things that the claim reviewer needs to look for. And like I always say, read that EOB so you know what you need to appeal in your narrative. Yeah. So what is the website for Fofidio Consulting? It is FofidioConsultingGroup.com. And there's several different links on that website to all the forms of information that I have out there. Thank you so much, Dr. Fufidio. We really appreciate your time. And I know we're going to be doing another podcast, dental insurance reimbursement. Is it worth it? And that's going to be very interesting as well. So we look forward to that one. Thank you and have a great evening. Thank you so much again, Phil. If you like our podcast and want us to keep it going, please leave a review on your favorite podcast platform. Leaving a review is a fantastic way to support us and help others discover our show. We really appreciate your support. See you on the next episode.