Medical Reimbursement for Dentists: What You Need to Know

Medical necessity is established by using diagnosis codes, and that is the biggest gap between medical and dental. We do not, on an ADA form, we do not have to use a diagnosis code. We just submit stuff all day long without ever having to diagnose why we did it. On the medical side, You can't even get a claim to go through if it does not have a diagnosis code. That diagnosis could be as simple as decay into the pulp or osteomyelitis or what we call an abscessed tooth. Welcome to the Phil Klein Dental Podcast. So today we'll be talking about you, not as a dentist, but as a medical specialist. We'll explore a game-changing strategy, leveraging not only dental insurance, but also tapping into patients' medical insurance by establishing medical necessity for dental treatments. That's right. As dental professionals, we often focus solely on dental reimbursements, yet many procedures qualify for coverage under medical insurance. By understanding how to articulate the medical necessity of certain dental treatments, dentists can not only enhance patient care, but also unlock additional revenue streams. Joining us to help us better understand all of this and enlighten us on the financial opportunities is our guest, Kandra Sellers. Kandra is an RDH with over 25 years in the dental industry. She is widely considered one of the most passionate and respected dental coaches. She is an educator in the field of oral systemic health, as well as founder and CEO of TIPS Medical Billing. That's TIPS, T-I-P-S, medical billing. Kandra will be joining us in a moment, but first... For many years now, we've recognized that buffering local anesthetics can reduce injection pain, speed up onset, and decrease the overall volume of anesthesia needed. However, the process of buffering has always been complex, time-consuming, and expensive. Until now. Introducing BufferPro. a single-use, sterile, self-contained capsule that delivers 0.1 mils of sodium bicarbonate into a dental anesthetic cartridge, raising the solution's pH to near physiologic levels. No measuring, no mixing, and no hassle. Join the growing number of dentists introducing BufferPro into their practices. To learn more, visit septodontusa.com. Kandra, thanks for joining us. Absolutely. Thank you for having me, Phil. I really am excited to share my passion with the industry. Yeah, so I've practiced for many years as an endodontist, and I never even thought about billing as a medical specialist. I didn't even know that those words even apply to a dentist. So before we get started, tell us what you mean by medical specialist. Well, we are a branch of medicine. We just happen to be called a dentist. We are no different than any other specialty. We are a specialist under the medical roof. Right, but we're a specialist, but we, you know, bill and operate under dentistry. And that's why people have dental insurance. So why... open up the opportunity for dentists to start looking at billing as a medical specialist? Because we can. When you say dental insurance, we are the only medical specialist that has a separate insurance policy that we can tap into, i.e. dental. Oh, that's interesting. So yeah, yeah, it is. If you think about an optometrist, say, you can have vision coverage on your medical policy as an extra, but it goes to your medical. We are the only medical specialty that has a separate entity called dental insurance, actually dental benefit. You're saying that as a dentist, we're the only healthcare providers that have our own specific insurance. So all other forms and services related to the healthcare industry gets billed under medical. Is that what you're referring to? Correct. Yeah, and we have our own code sets, PDT, which in medicine it's CPT. So how does a dentist bill dental insurance and medical insurance together? How do they do that? Do they do it at the same time? Do they bill for dental and then wait for their claim to come back and see what's covered and then bill the residual on the medical? And how do they know what procedures to use for the medical side? You can bill to both dental and medical. and be reimbursed by both. You cannot have a claim out to both at the same time. So whatever you bill to first, you would wait for that claim to come back and then go to the other second. There's really no state insurance commissioner that's going to tell you you have to go to one or the other first. So because they are completely different policies, you wouldn't be able to bill simultaneously. The thing to know about that is whatever we bill, We cannot keep a penny over what we billed. So that being said, so say you bill $100 to dental, they pay $50, and we bill $100 to medical. It has to be the same fee that's billed to both. And say medical pays $100 of that $100 billed, we would have a $50 overage that we couldn't keep. So we can't keep a penny over what was billed between the two. And what do you do? Does that make sense? Yeah, what do you do with the $50 that's the overage? So in that situation, if medical created the overage, we would give $50 back to medical. But we can keep up to the full $100. And that is one huge opportunity with billing to both because if you are in network with dental plans, you're writing off 30% to 40% of what you bill. So you can capture it on the medical side. We just have to be careful that we're not. you know, double dipping and keeping overages. Right. So the question is what procedures that a routine general dentist does, for instance, would fall under the category where they can build medical? I mean, typical composites, restorative dentistry, aesthetic dentistry, none of that can be built under medical, correct? That's incorrect. Okay, good. That's why you're here. I'm glad. I was hoping you were going to say incorrect. Otherwise, we don't have a podcast episode. That's interesting. So why is that incorrect? In situations with restorative tooth procedures, typically we cannot bill that. However, there are opportunities to bill that. Say, I mean, we have a big claim out right now for about $40,000 worth of restorative needs for a patient that has cancer. And that cancer via radiation and chemo for that particular patient has destroyed his mouth. And because of the destruction of his mouth caused by the cancer treatment, we were able to get all of his restorative needs prior authorized. submitted to medical. We're doing a whole campaign with that this year because there are so many oral cancer patients that are going to, say, a prosthodontist or a maxillofacial surgeon, whatnot, that are not billing to medical. And these patients either end up not doing treatment or, you know, doing treatment and really can't afford it. And they don't realize that their medical may pick up the bill for that. So I assume this would apply to an autoimmune disease like Sjogren's syndrome, for instance, where you have dry mouth and the manifestation of that dry mouth could be extensive caries. If those caries caused widespread destruction of the dentition, for instance, would restoring those teeth be covered under the medical plan? Potentially, yes. And because it affects the pH of the mouth and it destroys the mouth. just like the chemo and radiation. So it is always going to come back to the patients. benefit plan. I mean, I have been turned away by, you know, some insurance carriers because the patient doesn't have coverage for situations like that, which is the craziest thing I've ever heard of. But there are some really, really, really cruddy policies out there that do exclude that. And isn't that why we have medical coverage? For catastrophic events in that situation, that is a catastrophic event if you can't function and chew and get proper nutrition. So in your experience, Kandra, are dentists utilizing this? Are they taking advantage of the medical side of a patient's healthcare insurance profile? That's one question. And what are some of the procedures that are the so-called low-hanging fruit for being able to be billed to medical insurance companies without too much pushback? So the one you have to meet medical necessity. So whatever that is. But the things that we can bill are evaluations and even right out of hygiene. So if you are doing a head and neck oral cancer, maxillofacial cancer screening out of hygiene, you could bill your exam. If you're planning for surgery or sleep or whatnot, you can bill your exams. You can bill panorexes. You can bill CTs. tomographic studies, implants, grafting, surgical stents, interim and final prosthesis, frenectomies, wisdom teeth extractions, anything that's impacted in the bone. In your profession, apicoectomies, INDs, those are all billable to medical. In fact, endo is the great place because it's infection and medical understands infection and how that can kill somebody. So is it typical that when the medical insurance company gets the claim, do they send it back saying, well, this would fall under the dental insurance of the patient first? Or do they even know the patient has dental insurance? How would they know that? They don't. They may say that's dental. And that's a red flag for me that they're looking at your NPI and trying to discriminate against your provider type. And I have a nice little letter that goes back to them stating, no, we are asking for medical coverage for these reasons, and this is why it's medically necessary, and you need to pay us because right now you're discriminating against our provider type. If they are willing to pay an ENT for an exam or procedures, they can't discriminate against our provider type from doing the same thing. So let me ask you this, Kendra. What about the discussion between the doctor and the patient? Does the dentist need to make it clear to the patient that the dentist is intending to bill the medical insurance for the procedures that are being done in the dental office? Yeah. Yes, they should have it on their consent forms. And that's something that we put in place in our implementation. Do patients balk at that sometimes? Sure. Because they don't understand why a dentist is asking for their medical card. But when patients realize that what we're really trying to do is decrease their out-of-pocket benefit, they're typically more than happy to give us their medical card and say, yes, go bill my medical, because they understand medical. Where I do see sometimes patients not wanting that on their medical record is with sleep apnea. If they're in a profession, that sleep apnea could cause an issue with their job. then they maybe don't want that on their medical record that they have sleep apnea. That's the only time that I really see a big problem. Or if a patient's just uneducated about why it is we're trying to bill their medical. And, you know, it's great, you know, when you look at your specialty, how often do patients or do your referring doctors not want to send the patient to you? Because you're going to use up all their dental benefits and now the general practitioner can't. see the patient well they can but the patient and the the general dentist is a little bit brainwashed by this thing called dental benefits and that if they only pay a thousand to fifteen hundred well now the patient's not going to come back well you know that's the great thing about medical there's unlimited reimbursements there and you can preserve that and keep it for dental stuff We'll be getting right back to Candra in a moment, but first, thanks to GC America, we're now able to incorporate all the advantages of glass ionomer into a beautifully aesthetic, strong, long-lasting restoration. That's a great reason to try GC Fuji Automix LC. You'll love the convenient automix delivery system and ergonomic dispenser. which allows precise placement into the preparation. And GC Fuji Automix LC is bioactive, allowing for a high rechargeable fluoride release, which is ideal for high caries risk patients. And because it forms a chemical bond to tooth structure, even in the presence of saliva, there's no need for etchant and adhesive bonding. This saves steps and is ideal for challenging patients where access and isolation are difficult. And the small filler particles in the material allow for superb polishability and excellent aesthetics. So when you're thinking glass ionomer for your clinical cases, think GC America, a world leader in dental materials. To learn more, visit gc.dental. How many dentists, percentage-wise, do you think are taking advantage of this across the board? Not many. Unfortunately, it's getting more and more of a hot topic again. It was a hot topic when I started this journey. I mean, I am a hygienist. I was in practice management and I attended a course four different times on medical billing, you know, two-day immersion courses with the same dentist that was teaching it. And I could see that there was such a gap in this opportunity, but a lot of people had tried it and failed. I get those providers all the time and I understand why they failed. And that was because we can go to these two day immersion courses, which are fantastic. It's great information. It starts to shift our mindset as to the possibilities with medical billing. But how do we take that back to our team? Their gap is that, that exactly. And that's our niche is really. Having somebody to hold your hand through the entire process so that you're successful because it is different. It's similar, but it's different. And knowing the steps of how to get there. Most practices, just like a practice management coach, they need a medical billing coach to help them. Yeah. And how long do they need this coach for to get them in the right direction where they can do it independent of a coach? Well, that really depends on what they're trying to bill. If they're only trying to bill, say, sleep, that's, you know, that's a niche. If you're trying to do, you know, different surgery, sleep, you know, if they're trying to bill anything and everything they can in their practice, like for an oral surgeon, it's likely going to take a year. Because it's not only the billing piece of it, but the clinical documentation as well. Your documentation has to be up to par in order to meet medical necessity. So it's a marathon. It's not a sprint. It's not just a matter of submitting a claim. We got to have all the nuts and bolts and the pieces in place. So talk to us, Kandra, more about documentation. What do we need to be aware of as a dentist regarding filing a claim on the medical side regarding documentation? Well, the documentation isn't always asked for with the claim. But if it is, yeah, you want the documentation to meet medical necessity, which is why was it done? And I can tell you from. seeing a lot of notes um there's a lot of gaps in documentation on the dental side and i see all the time you know okay we did this filling but nowhere in the note does it say why the filling was done okay so the filling the filling was just done well why well it was done because most likely there was decay or the tooth was broken down or fractured but the Etiology is what you're talking about. You're talking about having the dentist understand the medical implications of the situation that that patient is undergoing that caused that dental problem that now is accruing bills based on fixing it. So it's more than just, okay, this tooth is decayed. We're going to fix it. You need to get to the underlying medical problem in order to justify billing under medical codes. Is that right? It's what we call medical necessity is established by using diagnosis codes. And that is the biggest gap between medical and dental. We do not on an ADA form, we do not have to use a diagnosis code. We just submit stuff all day long without ever having to diagnose why we did it. On the medical side. You can't even get a claim to go through if it does not have a diagnosis code. That diagnosis could be as simple as decay into the pulp or osteomyelitis or what we call an abscessed tooth. It could be bone atrophy. That's why we're doing a bone graft. Dentists are smart. You guys are all smart. It's not that hard, but it's coming back to your roots of what you learned in dental school. Right. And using the right documentation and the right terminology. Right. A crown is not a crown. It's a fixed prosthesis. In other words, yeah. So it's important for the dentist to look at it from the standpoint of the medical examiner, whoever's the medical insurance examiner. Is it typical for the dentist to communicate with the physician that is caring for that dental patient to make sure that their diagnosis and, for instance, the cancer patient? They don't have all the information as far as the details of the type of cancer necessarily. They might, they might not. Do they reach out to the physician to get some more clarity and details on the medical condition so they can go ahead and fill these medical claim forms out correctly? When it comes to a systemic condition like that, I absolutely love the MD on board. Absolutely. I want their blessing on it. And in fact, I mean, I've... Most of those doctors are really great, the doctors that I've encountered. And I will send them a letter of medical necessity and ask them to look at it, sign their name on it, enhance it, whatever they want to do. And most of them are more than happy to collaborate with us on that to try to get benefits for the patient because they understand it. Now, there are some out there that... are not that way as well. I mean, I've, I've ran into an ENT yet in one state that, man, she would not help me with the cancer patient. And she, she, she worked for, she actually worked at the insurance carrier side, at, at the insurance carrier side. I really want to say who it is, but I won't. But, you know, she said, she said that a brain tumor radiation to the head did not affect the mouth. Are you kidding me? Are you kidding me? And this patient's mouth had bombed out and she would not approve their treatment for restorative work. I was appalled by that. But we always have state insurance commissioners we can take that to too. So let me ask you about your company because it really intrigues me. You have a really fantastic idea that you developed into a service. So you engage on a business level with private practices. What do you do for them on an ongoing basis? Like how much interaction do you need to have with that office in order for them to run their practice where they're constantly taking advantage of medical billing? Sure. And that is a process. Like I mentioned, this is a marathon. It's not a sprint. I am on the phone with my clients every week, usually for two hours at a time. And I'm available to them. anytime after that as well. I'm always available to my clients. That's what this takes for them to be successful. My best insurance coordinators still need a lot of handholding and that's okay. That's why I'm here. It's kind of like when you invest in a, say a CT machine, you start taking CTs. But you don't know how to bill it to medical or you don't know how to read the CT or you get a CREC machine and you don't invest in the training that goes along with it. You're going to hate the CREC machine. You're going to think that it has crap. You know, it makes crappy margins. And, you know, it's the same thing. Medical billing is an investment in the practice and it will pay its ROI back tenfold. And actually, you just touched on my final question as we wrap up this podcast. And it's been very enlightening, Kandra. Very good information in this discussion. But my final question was, what is the return on investment for the typical dentist? Maybe not so much for the pediatric dentist, who may not be seeing much in the way of medical necessity related to the pedo patients in a pediatric practice. I mean, some, but generally speaking, I'm talking about a general dentist that treats adults, primarily adolescents and adults. What would be the typical return on investment based on hiring you? delegating a specific person, an employee, to be trained and handle these kinds of medical claims? Well, I do want to go back to peds. So if they're doing free nectomies, those absolutely can go to medical. If they have an oral surgeon coming in to take out wisdom teeth, that can go to medical. And their evaluations and their PANS, we should be looking at our pediatric population as far as airway. And we should be looking and having discussions about HPV because we are seeing oral cancers in those kids, in those teens. And if we are doing that, the evaluations can go to medical as well. Well, at least you know you're not going to hire me to work for you because I certainly don't know anything about this. So yeah, tell us about the ROI though. If a dental office never did this before, which it sounds like to me, many dental offices don't know anything about this. They're not doing medical billing. Am I correct there? I would say in the US, I mean, I don't know, it would be hard to poll. I would say less than 5% billed to medical. All right. So almost no one. They just don't know what they don't know. Right. And we even talked offline before this podcast that even oral surgeons who for sure would benefit from billing on the medical side, and many of them don't. They're just not familiar with the nuances of billing medical insurance for their procedures. So again, getting back to the ROI, if a dental office hires a coach like you, what is the typical ROI? I mean, do you transform that revenue stream into something they've never seen before because now they're tapping into the medical side of their patient's insurance profile? Well, the ROI really depends on how many claims they submit. I mean, I can guarantee we're going to get claims. Well, I can't guarantee. If I have a dentist that comes to me and wants to build a medical and they only submit two claims a month, well, the ROI is not going to be very good. So we have to look at that. That's a factor. The other factor is what it is that we are billing. in terms of if you're only billing, you know, exams and CTs versus surgical things. The other thing that we have to look at is increasing case acceptance because now we have another avenue for payment for the patient. And you're going to have an increase in case acceptance. We also have to look at fees. A dental fee schedule is... based off of dental allowances from dental carriers, as well as the NDAS. And you want to be in a certain percentile. It's not based on what medical allows. And so, you know, you want to look at that. On average, I see a periodic eval of $35 being allowed through much of the U.S. When medical, when... When documented properly and billed out properly, medical would easily pay $200 on that eval. So we have to look at that as well and what can be returned on that. And how many things are you writing off like CTs? How many CTs are you writing off because you know dental's not going to pay for them? What things are you writing off that you're currently not being paid for as a medical specialist? Yeah, we have a podcast coming up on that too as part of this series. You know, let's not give all the goodies away yet. But what is the best way for our audience to reach out to you if they have any questions? So the best way to contact me is go to my website, which is tips. So it's T-I-P-S medicalbilling.com. So that's the best way. Okay, great. Tipsmedicalbilling.com. Thank you very much, Kandra. We'll see you on the next podcast. Appreciate it. All right. Thank you. If you're enjoying this podcast, please leave a review or follow us on your favorite podcast platform. It's a great way to support our program and spread the word to others. Thanks so much for listening. See you in the next episode.