Get Paid for What You Do!

You're listening to the Phil Klein Dental Podcast So here's a scenario that probably sounds familiar. Mr. Jones comes in for his regularly scheduled hygiene appointment and periodic exam. The radiograph indicates a large restoration, one that should be replaced as there is concern of marginal leakage. There's also evidence of generalized wear and attrition. So our professional recommendation is to remove the existing alloy restoration and replace it with an all-ceramic crown. Mr. Jones is all in. He's excited. You see him the following week, and shortly thereafter, the final crown is seated. Now, keep in mind, financial arrangements were made with Mr. Jones, and as he was instructed, made his co -payment before being seated at the delivery visit. After that visit, the claim was submitted to the patient's insurance carrier for reimbursement to the office. However, nearly two months after completion of the case, Your office receives the explanation of benefits from Mr. Jones's insurance provider. And it's not what you want to hear. It's what we call an adverse determination. Detailing the claim was denied for, quote, not meeting medical necessity. Mr. Jones ain't very happy. He now owes your office approximately double what he expected to pay. You're in a tough position because you're pushing for the collections from the patient who happens to be very pleased with the work. Now, the other choice is adjusting the balance down as a professional courtesy. But that's a write-off, leaving you with a lot less money. So what went wrong here? What put your office in this position in the first place? To help answer that question and address how to keep this scenario from happening in your practice is our guest, Dr. Dominique Fufidio. She 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 dental insurance claims review process. Her goal is to have dental practices benefit from her proven techniques to build a better benefits reimbursement success rate. She has a website, foodfidioconsultinggroup.com, F-U-F-I-D-I-O, consultinggroup.com. We'll be talking to Dr. Fufidio 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. Dr. Fufidio, thanks for joining us. Phil, it's a pleasure to be here. So we all work hard in our dental practices. We all go to work every day trying to do the best we can. We try to provide the best care we can for each of our patients. So when it comes to patients that have dental insurance, how do we ensure we are actually getting paid for what we do? Well, that is a great question. And it's one that everyone wants to know the answer to. So although the question itself can't be easily answered, I have distilled the technique that I've been practicing for years down to four steps, and I've titled them the four steps to build a better benefits success rate. The first one would be practice best charting practices. Everything you should be doing would be in the patient medical record. So the second step would be appeal the adverse determination. Sometimes that first pass, it just doesn't work. the third step would be use your diagnostic information so you need to call upon the information you have from your clinical charting to demonstrate proof of loss and the fourth step would be speak to someone if you have to you have the right to something called a peer -to-peer call or a peer-to-peer review and you should use it these are the four steps that when coupled with the appropriate treatment planning they yield a much greater and more predictable success rate on your insurance claims submissions Tell me a little bit more about the steps individually and let's begin with best charting practices. How do we know we are actually employing quote unquote best charting practices? Right. Well, appropriate medical documentation is the key to success. It helps us when our memory fails. It has all the patient medical and dental history, the treatment specifics. It has their fun facts. Their ledger should be a running log of all the services rendered in, well, my office. It even served as a record of when statements were mailed out and appointments canceled. But the clinical progress notes, they should have everything detailed from the appointment. We all seem to think that insurance companies do not necessarily want to pay benefits that are rightfully due to the patient, but that's really not true. Since I transitioned to the payer market, I recognize that insurance companies are happy to pay benefits when warranted. They just don't want to pay benefits when a patient or provider rendering them are not entitled to them. Or to do so, they need to evaluate if a claim and the services on that claim meet what's called medical necessity for those benefits. So every insurance carrier will make business decisions regarding their clinical policies and what would constitute as meeting their criteria for medical necessity. We may misunderstand the denial or adverse determination and the message behind it. What we mean by that is, does the chief have decay and enough decay that it needs an indirect restoration as opposed to a large filling? But the insurance provider is not questioning your clinical judgment or expertise, but looking to determine, was that crown medically necessary? If your clinical documentation supports the need and it is submitted by your front office, then there should be virtually no problem having benefits reimbursed for the treatment at hand. I think if the provider's office has a better understanding of what we're commonly reviewing for from an insurance standpoint, then they can extract the key and actual critical information from the clinical charting and it can be provided to the insurance carrier and the determination can be made and most likely more favorably. So that leads to the next step then. You mentioned appeal the adverse determination. So even if you have the information from the clinical charting, there's still the possibility that the office gets back an adverse determination. So why would that happen if you think you're doing everything correctly? And how do you recommend handling the appeal process? you are correct many times the radiograph or the photo it doesn't show the entire story and that box 35 it's really a catch-all box and it can only handle a narrative of certain size or characters clearing houses have limitations and if a claim is sent to clinical claims review a dental consultant is reviewing the claim and can miss some of the critical information because we are all in fact human so if you receive an adverse determination and like you said we've done everything correctly appeal it the eob will state how to do so and typically i sent a copy of the clinical charting which is our step one so back to step one charting best practices they set you up to have all this information locked in the patient record so when you appeal and send new information it doesn't necessarily look suspicious it had the original charting date and a narrative stating that the doctor could have tested the tooth for crack tooth syndrome the testing is all the original documentation although insurance carriers recognize dentists are inherently good people there are special investigative units and their main job is to find dentists committing fraud so we want to avoid anything that could look suspicious. Government -sponsored insurance programs have taxpayer dollars at risk. And just like the dental office being audited, insurance carriers are audited as well. So if you have all the information in your clinical charting, and yes, you get through that first step and you still need to appeal the adverse determination, do by all means appeal and look back to your clinical information to do so. So as one of the key steps, you mentioned that the office should make sure to reference the reason the claim was denied. And by the way, you mentioned an acronym earlier, EOB, that's Explanation of Benefits, just for our audience. I'm sure they know that, but I figure I'd throw that in. So you want to make sure we reference as clinicians the reason the claim was denied. Can you elaborate on that and even give us an example? Absolutely. So I was just at the AADC meeting, which was the American Association of Dental Consultants at the summit for dental consultants in the insurance payer market. And the ADA manager of the third party payer issues spoke about ADA recommended language and that being a little more understandable to the office and the patient. We're seeing efforts to improve there from our organized dentistry bodies, but the EOB may indicate that a PA radiograph was not received. And maybe that's because it was a bite wing that was submitted, or maybe the PA did not capture the entire apex. That's why it's important to read the EOB and see what is it that we need to submit. Each company will have their minimum requirements for claims review. So it's pretty simple. You appeal with the information that was missing earlier or even just circle the information if you can locate it in your submission. Don't become irate if there's an NEA number listed. There was a PA. These things happen. There are integrations from other programs and sometimes image quality can be low. Something might not be recognized as a radiographic image. So things happen. And actually the AGD Impact, which has a news magazine for members of the Academy of General Dentistry, they just published a phenomenal article last month referencing a scientific study that was done. It was one of the large payers. I think it was back in 2012, and they were saying that the claim denials were broken down. denials versus acceptances rather. And they found that almost 75% of the claims were due to denied due to administrative reasons. After the appeal process, in the end, about 8% were denied due to clinical or technical reasons. So if your claim is denied appeal, because yes, you may be in that unfortunate 8% that are still denied, but that's a very small percentage. And with the good charting practices and documentation, Using that in your appeal and speaking to what is missing on the EOB, you should have a much greater success rate. We'll be returning to Dr. Fufidio in a moment. 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When I practiced endodontics in Philadelphia, we... made our claims to the insurance company and there were some insurance companies that routinely didn't send us anything back we just didn't hear anything so time passed we never got paid and we had to contact them and then say oh okay let's look into it and then eventually it got paid it seemed to me that this was the culture of certain insurance companies where they would actually just put these randomly in a pile and nothing gets done with those claims of course it was paper submitted at that point. It wasn't even when I practiced, we didn't even do electronic submission towards the end of my career. Yes, but most of it, no. So I believe those paper claims were put into a file that were just sitting there. And then when we would complain, they would take it out of that file and process it. And I bet you a certain percentage of those claims would sit there forever and never get paid. Is that possible that that was actually happening in your experience? What you're explaining to me does not seem foreign. but technology is really rectifying that. Okay, good. So it's not happening as much. It's not as prevalent as it was when I was practicing. Okay, well, that's a good thing. All right. So tell us about the peer-to-peer call. Is that after you've kind of exhausted everything? so that's a very good point the peer-to-peer call i like that as one of my last resorts because i've exhausted every other means of communicating the the patient's specifics to the insurance provider and there may be something that's been overlooked so peer-to-peer calls are something i'd love to spend a whole nother podcast on is it's something i specialized in when i was reviewing claims clinically but a high -level overview if you receive an adverse determination you can go right to a peer-to-peer call but some insurance providers considered the peer-to-peer call the final step. So I would appeal and if you receive another adverse determination, I usually appealed again and I included new information so it would actually be considered. But if it was still denied, I exercised my right to a peer-to-peer call. You can request it in writing in a narrative or ask your front office to call and arrange one. We may revisit this topic on another day so we can go over what to expect and the steps because it is a little more time intensive. But it's a great time to connect with a dentist, discuss the claim diagnostic information, and have someone explain why it was denied. So it may be a little ambiguous in that EOB language. So sometimes the peer-to -peer reviewing dentist, the consultant, they can overturn the adverse determination on the phone. Sometimes they will ask you to submit additional information in a certain way to them. They may need the locked and signed clinical progress notes in order to do so. It can go a number of ways, but I found it was always helpful that if my claim was denied, in the very rare instance, I had a crystal clear understanding as to why and I could explain that to my patients. But honestly, the awareness just helped me anticipate this for future similar cases and mentally prepare the patient for the possible adverse determination. I learned a lot in those peer-to-peer calls. So when you say peer-to-peer, is that dentist to dentist? That is a very good question because the title would imply that it is dentist to dentist. And when I would call on peer-to-peer calls and I would be returning them as a reviewing dentist, the offices would say... that they could not speak to me about a claim they were not my peer and i would actually ask them were they authorized to talk about the claim in its clinical capacity but they did prefer that i would speak with the doctor that is a misnomer because not every insurance company does require a peer-to-peer call be done dentist to dentist it really is just an opportunity to call the office acquire any other information about the case and maybe make a recommendation as to what else they could submit on behalf of that patient i do only know of one insurance company that did require that the dentist was the one that actually was on the receiving end of the peer-to-peer call I, however, would recommend that the dentist be the one on the call because you're going to know the most about the case, even if it's a hygiene. case of scaling and root planing, ultimately you are the one diagnosing that periodontitis and you are the most capable of talking about the requirements for the treatment. So like you said at the beginning, we just want to be paid for what we do. And that peer-to-peer call can be instrumental in bridging the gap in your clinical documentation that's being submitted and what the insurance company is really looking for. So I know you do a lot of consulting on this, which is great. And I mentioned in my introduction a scenario. where this patient was told this is their copay they had the work done they made their copay and then the insurance company denied it and then the doctor had to decide whether to write this thing off or go back to the patient so in this case what's your recommendation I usually did go through this process and I kept the patient informed because I never wanted them to be getting copies of their EOB and every time I was resubmitting they're getting more copies of the EOB in the adverse determination and becoming questionable of what I was doing as a provider. So typically my office gave a courtesy call to the patient to let them know that We're working on this. Sometimes there's just more documentation. Sometimes the first round is auto adjudicated in a way that's not in your favor. And Dr. Fufidio is working on this. on your behalf typically after going through these steps i did not have problems with reimbursement there were one or two early in my career that i did and i learned from those cases and then i worked with the patient and letting them know that i still stand by the treatment recommendation that we made and it's unfortunate that the insurance benefits that you have are not offsetting the cost of your treatment and did work with them to balance bill and collect the remaining difference it was never an easy conversation to have But that's why I'm hoping through consulting and coaching offices, they too can develop a keen awareness to know when these conversations may be coming. Because insurance benefits are great when we can use them, but they aren't designed to offset all of dental costs and treatments anymore. What is the level currently that you see in your experience of knowledge, expertise, and training of the staff that processes these claims? And how does your consulting business help these individuals, these staff members, and how do you identify that they actually do need training where they could significantly increase their rate of success with collecting from insurance companies? I think everyone can benefit from the information and the knowledge that I've gained over the years. Now, I noticed that you were speaking mostly towards the... office administrative team. But a lot of my coaching actually has to do with what the doctors and the clinical providers have to put in the documentation, in the clinical notes, in the charting notes, and then what the front office extracts from that. I think the front office administrative team, they do a great job trying to extract this information. But insurance companies and all of the technological advances, everyone is becoming very, very... hyper focused on the details and as dentists we are type a individuals we we know how to deliver the details so my coaching is really more tailored towards the clinical team so that way you have all the information you need and the foundation and then helping the administrative team just take the specific portions and communicate that because the administrative team they can communicate anything and everything under the sun but there's really fine technical details that are what the insurance companies are looking for. And this isn't taught anywhere. So I'm hoping to bestow my knowledge because I think the more you know, the more you forget that others don't always know this information. You decided to start your own company, Fufidio Consulting Group, which you're the CEO of, and you've pioneered this unique coaching offering, which is really something that is needed. As you say, there's definitely not a lot of it in the dental school curriculum on this. That's one of those things that the dental school just expects you to figure out when you get out there, learn the hard way. You know, Phil, it's funny you say that. I was speaking with another media outlet the other day, and they were saying, why don't dentists know this? And why don't the front office administrators know these pieces of information? But dentistry, it's just so technical. A four-year traditional curriculum, some postdoctoral programs, whether it's a residency, an AEGD, a GPR, and your first couple of years in private practice, you're focusing. on the clinical technical aspects you don't have time to immerse yourself in some of this that you think is considered an administrative task that maybe someone else in your office would be able to handle but that's why I'm realizing that a lot of getting paid for what you do comes back to the clinician, not just treatment planning it, but documenting it appropriately, and then making sure that the appropriate information is submitted to the carrier that's going to be evaluating the benefits to see if they are medically necessary and fit. Also, I love the ADA materials that have been published. They're posting a lot of information lately through the Council of Dental Benefits. And then, like you mentioned, my website, I'll be posting blogs that will include tips, tricks, a lot of trends. in the upcoming weeks. I know a lot of that sounds too good to be true. So there will be seminars and continuing education. And then please anyone reach out. You can email, schedule through my website directly and we can have a discovery call and see what it is that you're most interested in, where you feel the most pain and see how I can help with that. Yeah, that sounds great. And also I would like to let our audience know that you came out with a great ebook. that we posted on VivaLearning.com. If you go to VivaLearning.com, just go to the ebook section and you'll see an ebook. What's the title of that? Benefit Determinations vs. Treatment Recommendations. Benefit Determination vs. Treatment Recommendations. It's free. You just have to log in and you can grab that ebook. There's lots of good information. I took a look at that. I wish I had that when I was practicing. If you've been enjoying our podcast, we'd love to hear your thoughts and feedback by leaving a review on your favorite podcast platform. 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