Code & Collect: Unveiling the Secrets of Medical Billing Benefits

It doesn't mean that everything that we do is going to apply to deductible, even if deductible hasn't been met. If I go into an MD for an evaluation, I pay a $15 copay for regular, in my primary care, and for a specialist, $50. It never touches deductible. When it comes to same-day surgeries because of infection and pain, we often see the same thing. It's like going to an urgent care, and sometimes that doesn't apply to deductible. It's based on the procedure code and the encounter. Welcome to the Phil Klein Dental Podcast. As a dentist, you are a medical specialist. That means it is totally appropriate and acceptable to tap into a patient's medical insurance for procedures that fall within the realm of medical necessity, even if they're done in your dental office. And there are plenty of procedures performed in our operatories that do fall within the range of medical necessity, ranging from oral evaluations, CT scans, cancer screening, soft tissue surgeries, bone grafting, to treatments for conditions like sleep apnea, the possibilities are vast. And when you utilize the patient's medical insurance, your office not only takes a lot of money left on the table when not charging for these procedures, but also enhances case acceptance. It also serves as a powerful marketing tool for your practice. To tell us all about it is our guest, Kandra Sellers. Kandra is a registered dental hygienist 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. 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So whether you're taking your first step into digital dentistry or you're looking to add additional equipment, check out Shining 3D Dental's complete digital dental portfolio. To learn more, visit shining3ddental.com. Kendra, welcome to our show. Thank you for having me. I'm super excited to be here today. Yeah, so we're happy to have you back. So let's begin with me asking you, can a dental office build dental and medical insurance companies? Number one, can they build both? And how does that work logistically? How do they do that? Absolutely, they can. We are one of the only specialties. Well, we are the only specialty that has two different... places that they can go for reimbursement, that we can go for reimbursement via dental and medical. The biggest thing to know about that is that you can't have two claims out simultaneously. You need to wait for one to come back before you submit to the other. And we can't keep any more, we can't keep a penny more than what we billed. So if there's, you know, $100 that was billed and we between dental and medical, we recoup more than $100. We can't keep more than $100. So we can't make money off of that. We can only get $100. So tell us how billing on the medical side, a patient comes in and they have medical insurance. They also have dental insurance. How is billing on the medical side different than the dental? And we talked about that briefly before where it comes down to determining that there's a medical. So talk about that and also the codes. How difficult is it for a dental team who's in the billing department of a dental practice to kind of switch gears and go, okay, now I'm billing medical. Is that going to be disruptive and difficult and the learning curve is going to be steep? Well, the biggest difference, let's start with the first part. The biggest difference. between medical and dental billing is the code set. So you have CDT codes for dental and CPT codes for medical. And there's not always a one-to-one crossover. So the whole thing of cross-coding is somewhat of a myth. Sometimes there are a one-to-one ratio, like say with Panorex, there is only one medical code, one dental code, but there's often not a one-to-one ratio. on and there might be more medical codes than there are dental or vice versa that you're trying to cross cross code the biggest difference in my opinion is the fact of diagnosis codes. In dentistry, we don't have to use diagnosis codes to explain why we did the procedure that we did. And I often hear from, you know, dental practices that, oh, you know, we get asked for so much supporting document, blah, blah, blah. Well, I get that. It's because they're trying to understand why you did the procedure that you did because you didn't have to tell them why. via diagnosis codes. So they're trying to get you to establish medical necessity for the reason why you did that dental procedure. Medical necessity is solely diagnosis codes and there's over 72,000 diagnosis codes for our entire medical profession. So there's a lot of them. So I talked to a periodontist friend of mine recently before we had this podcast just asking him about this because he practiced For 35 years, he just recently retired. And he said, yeah, there were some oral surgeons that were doing medical billing, but for the most part, it was complicated. It was time-consuming. It was frustrating. So obviously, there's what you just said. There's so many codes and they're not correlated one-to-one. You can see why dental offices aren't utilizing this. So they have a choice, dentists. Do they want to learn this on their own? Or do they want to hire someone to teach them how to do it? Or is there... an online course that tells them how to do it. And I know you're a coach and you teach it. So what is your suggestion? And I know, of course, you want to build your business up, which is great. But what is your suggestion to the dentist out there that says, yeah, I want to do this, but I'm busy. I see patients all day. My staff is busy. How do I transform my practice into one that can efficiently build procedures that are appropriate, that have medical conditions related to them? to medical insurance companies? Well, I can tell you what I've seen in the industry and what hasn't worked. What hasn't worked is going to a two-day immersion course and then trying to take it back to your team. I mean, how are you going to do that? I mean, I did that four times. I did that as a hygienist. I did that four times. And I thought, wow, there's a huge opportunity here. I could see the other people in the audience after those two-day immersion classes, and typically it was the doctor that was there, or maybe an admin person, or maybe both. Maybe they came together. But what about the rest of the team? How are you going to implement this, and how are you going to get everybody on board? Because everybody does play an integral piece of this puzzle. So that's what I have built my company on is that niche of, okay, well, let's get this done. And it's just like anything else that you bring into your practice. You've got to invest in it if you want it to work. But I can guarantee you that it works. It is possible. possible. And, you know, you just, you just have to be on board. It's not going to work if the dentist says, you know what, go teach my team. Because guess what, the dentist is responsible for the procedure code and the diagnosis coding, not the assistant that's sitting next to them. Now they can tell their assistant what they want on that form, but it should be that the diagnosis has to come from the doctor. Right. Working with your company, I'm not here and we're not, and I'm telling the audience now, We're not here to plug Kandra's company. The concept is that this is not something where you can just quickly learn about it or even binge a two-day class and come back and implement. You actually need someone you can call because things come up all the time. Kandra said there's 70,000 medical codes. They're not correlated to dental. And the whole concept is different. The whole concept of being restricted on the dental side to a frequency. of x-rays. You can only take so many x-rays like this in a year. You can only see this, do this procedure. This crown was done four years ago, so we won't approve it. It's all restricted. Whereas on the medical side, it's more for the patient's health. They don't look at things restricted as they do on the dental. So it's really something that I think our audience should look into as far as utilizing the benefits of medical billing. Let's talk about the bottom line for the practice. How does billing both medical and dental insurance companies actually help the revenue of the practice? Well, that's going to depend on how many claims you submit. You know, if you're playing, if you're dabbling, or are you really embracing this process? I recently did another podcast just on this of a patient who actually has been in. He created a company within dental and he sold it and now he's retired and he's going through cancer therapy. And he got a statement at the end of, at the beginning of 2024 from his, his medical insurance carrier. And they basically said, we basically paid almost a million dollars in medical treatment for your cancer this year. Your providers by going to in-network providers. wrote off close to a million dollars. And Mr. Patient, you paid out of pocket about $7,000. Now that's one patient that has contributed a million dollars to the medical professionals that he saw. What do we have to do as dentists to get to a million dollar practice? We have to see at least a thousand patients that have a thousand dollar benefit on their dental side. But this comes down to shifting our mindset and our focus on what's possible with medical because everything in our practice has been dictated by this thing called dental benefits. How much we charge, how often we charge, when we charge. And the fee schedules are based on the NDAS and the fee schedules that are allowed by our dental benefit plans, right? They're not based on a medical plan. And if you put side by side, and I can show this to people. If you look on my website, it's there in one of the articles I wrote, which is in Dental Economics, April of 2023. There is a graph in there that shows an in-network provider. This is a dentist. They are in-network on the dental side as well as the medical side for that same medical payer. And you, if you do the math, you will see. that it is 2 to 12 times higher reimbursement submitting the same exact thing to medical versus dental. Dental economics, you mentioned April 2023. I guess they can look that up online. Yeah, they can go to my website and see it too. I think it's actually labeled that, I don't know why, it's labeled as May 2023, that article. But you'll see at the bottom of my resource page are where the articles and it's there. So dentists are leaving a lot of money on the table, are they not? By not utilizing medical billing. Yes. What part of dentistry is the greatest missed opportunity when it comes to billing medical insurance companies? Well, I think there's so many. Evaluations, CTs. You know, how many times do you see a patient and they're over their two evals that they get per year on their dental benefit plan? So you don't charge them for the evaluation, even though they came in with a toothache and exploded your schedule. And maybe you did same-day surgery on that patient as well. How many times do you take a CT and don't charge for it? Um, those are just super simple things. And then you have obviously, you know, the surgical side of things that go well beyond a, um, dental benefit. You know, if you're looking at a single implant, you're five, $6,000 in, and now the patient is paying that all out of pocket. It goes well beyond their thousand or $1,500 benefit or in your specialty. you know, with endo, how much of that goes past that $1,000 to $1,500 benefit that is now out of pocket. And what that creates is patients that just don't get treatment. We'll be getting right back to our guest in a second. But first... With countless dental composites on the market today, choosing the right one can be overwhelming, yet a few products rise above the rest, and VoCo composites lead the way. For over a decade, Grandioso's tooth-like physical properties have remained unmatched by any other restorative material. With its stunning aesthetics, exceptional durability, and superior handling, Grandioso stands out. as the clear choice for all of your composite needs. And if you're looking to simplify posterior restorations with a single-shade solution, check out Admira Fusion Extra. This omni-chromatic nano-hybrid covers all 16 Vita classical shades with a single shade. It achieves this without compromising strength, handling, or radio opacity, providing fast, strong, and aesthetic posterior fillings. Join thousands of dentists who trust VOCO for proven performance, superior aesthetics, and lasting results. Explore VOCO's full range of composite materials and request a sample at voco.dental. Right. But the dentist who hears this podcast can say, yeah, but a medical insurance company is not going to pay for an implant. That's a dental procedure. And what do you say? They absolutely will. Well, and I'm going to say implants are kind of a wild card because Medicare does not cover implants. So there's some medical carriers that will exclude them from their policies as well. But that being said, what often goes with an implant? Bone grafting. And they pay heavily on bone grafting. So we can sometimes look at a total case fee and bill under bone grafting and forget about the implant. So the key thing, though. to bring the dental procedures into the medical world is to determine the medical implication, the whole health of the patient, right? The total health of the patient has to be brought into the dental case. An example of that, of course, could be Sjogren's syndrome. You could actually say that this syndrome has caused massive destruction of these teeth because there's no salivary flow. And because of that, it's a medical condition and therefore it needs... Dental rehabilitation. Is that an acceptable approach to get paid by a medical company based on that approach? Absolutely. I think even there's way more people that have cancer. So, you know, what about the cancer patient that has had radiation or chemo? That will bomb out their mouth. Right. Because it'll change the pH. It'll destroy their dental. Right. So that would be the story. Right. They get radiation treatment and the dentist sees the patient and they know who the MD is, who the general practitioner is, the internal medicine person that's kind of quarterbacking the cancer treatment for that patient. They get in touch with that doctor and do they need any kind of like letter from that doctor to say that this patient is under aggressive radiation treatment and then... The dentist comes in and says, because of this aggressive radiation treatment and the cancer that this patient is suffering from, we needed to do immediate rehab of these teeth. That dental work is now considered acceptable under medical plans to pay for that. Yes, as long as, again, as long as the patient has benefit for it. I mean, there are really cruddy... policies out there that will exclude that scenario. They're far and few between, but they are out there. You know, I can never say always or never. There are exceptions that will, you know, exclude that, which is insane. Right. So, but the main thing that you've been talking about is the CT, the CBCTs that are in the offices, they're not getting utilized to their best potential. As far as medical billing, that's probably where most of the money is being left on the table. Does that sound right? Well, I think that's an easy thing to capture. You know, when we talk about the surgeries that we do or the sleep appliances that we do, you know, there's a lot of money in those procedures. But we typically don't bill out some of it or we bill very little because... We know that dental's not going to pay for it. Like bone grafting is one of those things. I often see, you know, on average around $350 for a bone graft. Well, I'm sorry, but you're probably... barely recouping your product cost, let alone your expertise that it took to place the bone graft and the fact that that probably blew up your schedule because you probably were placing it after somebody came in with an abscessed tooth that you extracted and there was a huge bony defect because of the infection. You know, typically what I see in that scenario is the practice will bill out an extracted tooth. They often write off the exam. They often write off the CT if they took one. They often, maybe they'll bill for the bone graft, but sometimes not. And pretty soon they have a $300 charge for an emergency surgery in their office when it could have been closer to $2,000 if you actually bill out what you actually did. So typically, Kendra, what kind of return on investment do your clients see after? engaging with your business, are they saying, wow, Kendra, I wish I did this 10 years ago. I can't believe how much money I left on the table. Yeah. And it's empowering them to have another resource of reimbursement. And, you know, I was just talking to a dentist about this. She's fee for service. And, you know, she said it has really empowered me and my team to offer more. instead of being limited by this $1,000 to $1,500 and say, hey, we have another avenue to try to get you reimbursement. Patients understand that they may have a deductible that they have to satisfy, but I can also tell you that deductible is, it's code driven. It doesn't mean that everything that we do is going to apply to deductible, even if deductible hasn't been met. My own insurance policy, if I go into an MD for an evaluation, I pay a $15 copay for regular in my primary care and for a specialist, $50. It never touches deductible. When it comes to same-day surgeries because of infection and pain, we often see the same thing. It's like going to an urgent care, and sometimes that doesn't apply to deductible. It's based on the procedure code and the encounter. I mean, I can tell you I've had a $75,000 case that was paid at 100%. That's what was billed. 100% was billed and paid. And the patient only paid a $250 deductible out of all of that. And those were dental procedures? That was a full mouth reconstruction. Wow. the grafting, the implants, the interim prosthesis, the final prosthesis, all of it. Right. That was all done through medical insurance and paid for in full. Yeah. That's impressive. So let's talk about case acceptance. Obviously, this all goes along with case acceptance. So give us an example of the interaction between a dentist and a patient where the dentist is saying, hi, Mrs. Jones, we're happy to see you here. Let's talk about the treatment plan and here's what your insurance looks like. And then how does that dental practice bring in the medical side and explain to the patient that even though you're in a dental practice, we're going to bill your medical company. How does that work? That's pretty easy conversation because again, if you look at just their dental benefits, the treatment's likely going to go well over what is allowed. And so the patient is more likely to say, well, you know, this is kind of elective. I can do without that tooth and not go forward. You bring in medical insurance and say, you know, here's what your medical insurance looks like. We have another stream of potential reimbursement for you. We'll go ahead and bill your medical to that. If the patient has any inkling that their medical may reimburse, they're more likely to follow through on treatment. Now, that being said, I would definitely make sure that you have your financials in place because if it does go to... deductible. The patient, what you need to know about deductible, that is still a benefit to the patient. We can't control the patient's policy, how good it is, how bad it is. All we can do is, as a courtesy, do our due diligence to bill it to medical. Patients understand their deductibles on the medical side, and they understand if it has to come out of their pocket, why. A lot of patients wait until the end of the year, just like with dental. They wait till the end of the year to, you know, do a procedure because they're waiting for their deductible to be met. So that is a benefit. Yeah. So let me ask you this. So in that conversation with Mrs. Jones, you mentioned that Mrs. Jones said, well, it's kind of an elective thing. I'll hold off. But should the dentist disclose to the patient that they have to position the submission of this claim? as a medical-related condition? Because elective isn't the same thing as a medically-related condition. So you don't want to misrepresent the case to the medical company and then have the patient think that the doctor is kind of being crafty. Oh, for sure. I mean, your medical necessity with a lot of these things is infection of the bone. or atrophy of the bone that warrants the bone graft and the placement of the surgical fixture, i.e. implant. Yeah, you would be utilizing your diagnosis codes to meet medical necessity in order for that to be reimbursed. Right, but if the practice is primarily a cosmetic practice. If you're doing something for cosmetics, yeah. Okay, Botox is a great topic right now. A lot of offices are doing Botox. Well, doing Botox for cosmetics is not medically necessary, and you can't bill that to medical. Now, we are getting a lot covered with Botox for TMB. issues and doing injections to try to help TMJ pain. Or the hot diagnosis for that, and it's well written in the medical policies, is oral mandibular dystonia. If that applies to why you are doing the TMJ treatment and the TMJ Botox for Botox, then that would be covered by medical. But if a patient comes in that has broken down teeth throughout their mouth, the idea that the dentist is going to do a full mouth reconstruction because if they don't, the patient can't chew properly. And if they don't chew properly, their whole digestive system breaks down and then they end up having indigestion and acid reflux and many other digestive problems, which in a sense is a medical necessity. But that, of course, is stretching it and that's not going to fly with the medical companies, I assume. Well, I can tell you that's going to be a little harder to get through medical. I would assume so. You know, it has to be substantial. You know, some policies will not replace just one tooth with an implant. And so here's where part of that comes in is, and where you want to bring in systemic conditions to get implants covered. If you are, if an implant is not. a covered benefit. They're not going to pay for the surgical stent to place the implant. They're not going to pay for the interim and final prosthesis, i.e. crown, or whatever it is. So we can't, none of that, if the implant isn't covered, none of that is going to be covered as well. But that being said, you know, bone grafting, if we look at total case fee, you know, then we allot the dollar amount towards maybe bone grafting. And I can tell you that there was one case and it only happened one time and it would be great if it happened more because we're out of network on the medical side most of the time, unless you decide to go in network. The insurance carrier came to me and said, hey, we want to negotiate the fee for the bone graft and this treatment. And so. You know, I did some research and this was going to be a full mouth bone grafting situation with severe atrophy and pneumatization of the sinus, nerve impingement, that kind of thing. And I said, I went back, I did a little research as far as in that area, what, you know, what is being reimbursed for those procedure codes. And I said, okay, $9,500 per quadrant of grafting. Within 15 minutes, I had an approval from the medical carrier. Wow. Yeah, that's impressive. There you go. So I was like, I went back to the medical care. He said, can we do that for all of the doctor's surgery? No, this is just kind of a one case. But what I'm trying to say is, you know, there's a huge opportunity there. And again, our minds go to what dental reimburses, not medical. And our fee schedules reflect that. Yeah. And your expertise in this is invaluable. I mean, when you're working with someone like you, in these kinds of situations, to get a practice going in this direction, you need to have a mentor like you to get it off the ground and move it in the right direction. Otherwise, it becomes too frustrating for the practice and they stop doing it and they lost all this revenue, left all this money on the table. I do want to ask you, as we wrap up this podcast, Kendra, about marketing the practice. How does the dental office increase their patients of record by using the concept of... you know, accepting medical insurance for their dental treatment. How do you get that message to the patients? And does it work to bring more patients in? Yes. So you have to market it, obviously. But how many patients are not coming into your dental practice today because they don't have dental benefits? Because here's the deal. People that are out there, potential patients. feel that they don't come to the dentist because they don't have dental benefits. They don't have a dental policy. And so then they just think, well, how am I going to pay for that? They don't come to you. I can guarantee you they're not coming to you if they don't have dental benefits. There's very few people that are cash paying in your practice. I mean, do the numbers on how many patients come in as cash. They typically don't. And, you know, now we're seeing so many practices going out of network with dental benefits. dental benefit plans. So what is the other avenue of marketing for patients? And it's via medical. You can see a patient and do a full evaluation, do a maxillofacial and oral cancer screening on them, and we can then bill that exam to medical. And guarantee there's other things in that exam. If you're screening for sleep apnea, if you're doing periodontal charting for infection, all those things can be part of the process of billing it to medical. And now they can see you. And now you can get them in, wow them, and give them a treatment plan that they can accept. So how do you get the word out to the prospective patients before they come into the office that you can help them with this? You just have to phrase it in your marketing. Yeah, you'd have to market it as such. You know, hey, if you don't have dental benefits, we can still see you. There's a caveat to that. You have to be, because you're out of network, you would have to be seeing PPO type plans, which the majority of patients have. It couldn't be an HMO or an EPO that is a closed network. They have to have out of network benefits, but more patients have out of network benefits than. than not. People want the option of being able to see the providers that they want to see without boundary. So it's definitely more will have PPO. The other thing that you can do is go to your urgent cares and your emergency rooms and let them know that you are taking medical insurance plans. So if they have a patient that comes in with a toothache, please send them your way. You know, I mean, that that's a huge opportunity for you. Yeah, that's an excellent, excellent strategy. Kendra, again, great having you on the show. Lots of information on this one. And we definitely encourage our audience to visit you online. And if you could just mention your website real quick, and then we'll wrap it up. Sure. It's tipsmedicalbilling.com. So T-I-P-S medicalbilling.com. There's a contact page there. If you'd like a complimentary medical billing analysis, I'm more than happy to do that and plug your numbers in and see what opportunities that you have for medical billing. Excellent. Thank you, Kandra. Have a great evening. And thank you so much for spending time with us and enlightening us on this very important topic. Absolutely. Thank you so much for the opportunity. 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.