Oral Cancer and Head and Neck Evaluations: The Role of the Dental Practice and Getting Paid Through Medical Insurance

You're listening to the Phil Klein Dental Podcast There are many dentists today that do oral cancer screening religiously. Every time a patient comes in, they do a thorough examination of the oral cavity and they do a very thorough head and neck evaluation. But on the other hand, there's a lot of dentists that don't. One of the reasons why they don't do this is because they don't get compensated commensurately from the insurance company. And there's restrictions, as all insurance companies have, on how many times you can take an x-ray and how often they would pay for this and so forth. So some dentists shy away from it completely. But there is an opportunity on the patient's medical side. Medical insurance does cover this as long as it's determined that it's a medical necessity, which according to our guest, Kandra Sellers is not hard to do. She specializes in training dental practices on how to take advantage of a dental patient's medical insurance to pay for things that are done in the dental setting. And she's very good at it. And we're very happy to have her on our show. She's a registered dental hygienist for 25 years. And she's the CEO of TIPS Medical Billing. So she's going to talk about the role of dentists in early detection of cancer. And obviously, she's going to be bringing in the aspect of using the patient's medical insurance to get compensated. We'll be introducing Kandra 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. Kandra, thanks for joining our show. Thank you so much. I'm excited to be here. So we briefly talked offline, Candra, about a visit you had to your ENT. And you weren't exactly enthused or overwhelmed by the head and neck exam you got, which obviously you're a big fan of. You've been trying to implement this in dental offices, not only for the patient's well-being and early detection, but also it's a revenue stream for the office. And it's billable under their medical insurance. And you talk a lot about that in previous podcasts. So tell us about this experience you had with your ENT doctor and why this is relevant to the dentist's role in early detection of cancer. Well, I actually saw an ENT for some things, and he was great about wanting to do a scope of my throat and of my nose. But I can tell you that his oral evaluation was lacking, as well as him not even understanding anything about HPV and the lumps that we're seeing in the neck. And I had to point out the lumps in my neck, which was one reason I was there, before he really even dove into it. And then I furthered the conversation with him, and pretty soon I was educating him more than him educating me as the ENT. I would expect more, I guess, out of a specialist like that. We know our primary cares are really weak on that. I mean, you're lucky if you get a tongue depressor in your mouth for two seconds. I've actually had them ask me about my tonsils and now I'm like, I don't have any. I get that. So right now we're in a situation where the medical profession is obviously not a team of doctors that we could rely on thinking that when our dental patient comes in to see us, that that patient has gotten a full comprehensive head and neck exam, right? So as dental professionals, it would behoove us for us to do it and it's better for our patients. So talk to us about the head and neck exam or what we call the head and neck evaluation. How do we get the team prepared to do this on a regular basis? And how do we make sure we get compensated for it commensurately for the time we put in? Yeah, I mean, it is our wheelhouse. We are the only ones that spend that amount of time that often with our patients. It is our responsibility to screen for oral cancer as well as sleep apnea because we are the ones that they see the most and we are the ones that are literally in there for a significant amount of time. So I think it's really important for... a patient to experience the same thing, no matter what provider in the office they see. And if you need education on that, we are going to be rolling some things out this month, actually, because it is oral cancer awareness month, but we are going to be the carry free co-op. And part of that, we're going to be rolling some things out that'll help guide practices through this as well as videos as to how to do this. But you can also, you can also go to I guess, the oral cancer.org website. And there's some great videos on there about how to consistently look at this region in whole. And I think, again, the experience should be the same, whether they see me as a hygienist or somebody else. It should be very consistent within the practice. I also believe that and this is what I did when I was practicing clinical, is I did the oral cancer, the maxillofacial and oral cancer screening, as well as the doctor came in and did it a second time. Because there were times that, you know, I maybe missed something, not missed, but, you know, your tactile sensitivity is different than somebody else's. So I think, you know, it's... It's like having two sets of eyes on the patient. We do that during that evaluation. So why not have somebody else evaluating the head and neck as well so that we are completely thorough? But I do believe globally it is our responsibility, and this is part of our preventative philosophy in dentistry to do this. And it just needs to be consistent. Actually, I think it's also a really great way to start your appointment with the patient instead of sticking them with a metal probe. So don't stick them with an instrument. Start with a little nice head and neck massage. Get them relaxed. Get them calmed. Walk them through it. Communication during the process is super important, you know, because when you use the word oral cancer screening, they get a little nervous about that C word. So walk them through it. Tell them what you're feeling and why you're feeling for different things. But that being said. We are not just doing OCS. And so our documentation needs to be better than that. OCS, oral cancer screening, I often see that in a chart note and it'll say normal or within normal, you know, within normal limits or negative. Well, that's not good enough documentation. We are not just doing OCS. We are checking the jaw joint. We are checking the neck. We're checking lymph nodes. We're checking all of these different things. And we need to document it as such. And when we do that, we are able to get medical to pay for that evaluation. We are not just looking at teeth. We are not just counting teeth and evaluating teeth. We're doing so much more than that. We're oral physicians. We're oral health care providers. And we need to document it as such. And when we do so, we can get paid. by medical for that. And I really believe that often practices are missing this step, kind of like with blood pressure and other tools that we have in our toolbox. We're sometimes not doing those things because we are bound by this low reimbursement on the dental side. We don't slow down long enough to do these things that are super important and life-saving for our patients. So how often do you recommend doing a head and neck evaluation? And when does the CT scan come into that regimen? Is this something that you would typically do at every re-care appointment based on the patient's re-care schedule? That's a great point. I did it every time I saw the patient. If I saw the patient four times a year on a three -month recall, I usually did it two times out of that. Also, you can actually do a screening. panorex, what we call an orthopanogram in medical, you can actually do a screening orthopanogram yearly or whatever you as a team decide is relevant for recare and for screening of maxillofacial and oral cancer. You can do that every year and be paid by medical for that. If you see an abnormal radiographic finding, you're going to move it to a CT and you're going to identify what you're feeling. So that's a great point. both those things can be reimbursed by medical. And we can slow down and we can do these things and get reimbursed two to 12 times higher on a medical fee schedule versus dental. And I think it's important to point out, Kendra, that you have a whole business built on this, TIPS Medical Billing, where you train dental personnel about how much money is actually left on the table that they're not utilizing. And they're typically very restricted by the guidelines. the stringent guidelines of insurance companies that tell them how much they could bill for and how often they can bill it. But you found in your career, and you made a business out of it, is that using or utilizing the medical insurance that a patient may have, those restrictions are kind of go by the wayside. And because as long as they're proven to be medically necessary, then it's fair game to do those procedures and bill for them in many cases as often as you need to. Is that right? Absolutely. There's no limit to how many exams you do per year. And, you know, what I can say with oral cancer, age doesn't discriminate anymore. So we need to be elevating our game on this because it is the 11th deadliest cancer in the U.S. And we know that if we even see a spot the size of a... a pin it could be stage four already we need to do more for prevention we need to be screening and trying to catch this early so that our patients have a better chance at living and you know there are advanced screening devices that do work and they've been around a long time and they've been a long time they've been around a long time in medicine too And these fluorescent lights are used in medicine for patients that have lung cancer and things like that. I saw that happen with my mom. They used the same type of light when they were doing part of her lobe dissection. And, you know, why aren't we using those things to prevent? Why are we not taking a pan? You know, in dentistry, we can take a pan or an FMX every three to five years if we allow dental benefits to dictate that. When we could be doing a maxillofacial oral cancer screen with a pan every year or every two years, whatever your protocol becomes. I think there's just not, you know, we're trying to establish more protocols and recommendations through our co-op to give to providers because I think we all like checklists. We all like protocols. So it's time to level up. Yeah. So, and those are all great points, Kendra. Now let's talk about throat cancer. That's on the rise. That is something that is directly related to HPV. And there are very simple tests that a dentist can perform in the office using a longer swab to get down to the pharyngeal area, which is just behind the typical purview of what we're supposed to be treating, which is the oral cavity. It's just right behind it. So what's your feeling about pharyngeal swabs and testing for early throat cancer? based on the rise of these kinds of cancers attributable to HPV virus? I'll be honest, I don't know much about the swabs. What I do know a lot about is what oral DNA has had had out for a long time. They have an HPV test that tests for 51 strains of HPV. And it tests beyond the... whether you're active or not, this virus lies dormant in our body. It's kind of like when you have chicken pox when you're a kid and all of a sudden shingles appears as an adult. That popped out and that's exactly how HPV is. And in middle age men and women, more men than women, we're finding those lumps and bumps on their throats. And you'll feel it when you do the tactile evaluation. And men notice it more, I think, because you shave in that area. So you notice that bump, you feel it. But a simple saliva test is all you need to do to find out if you're carrying the virus. Right. And many of us carry the virus and it's basically inert. It doesn't really bother us. However, the swabbing is something where you just, it's a long swab versus a short one that we're accustomed to. It reaches back in the pharyngeal area and then you send it off to a lab and the lab will... whether or not certain HPV strains are present. When you do this on a regular basis, there's a higher rate of throat cancer when this particular HPV virus shows up consistently in that lab test over a period of time. So it's a matter of the prevalence of this virus over time. And also having your tonsils in adds a greater amount of risk because this HPV virus loves to hide in the crevices of the tonsil, which is kind of the origin of where this throat cancer begins. So that's something that has to be looked at as well. And I'm sure that could be covered under medical insurance, which is, again, something you teach all the time. So what are some of the things an office should do internally to work with their team to make sure that there's a process, a system in place so that head and neck evaluations are consistently given? They're given in the most efficient way. You get paid for it and everybody's on the same page. How do you start that process? Kendra will be right back to answer that question. But first, if you're looking to raise the bar with your adhesive dental procedures, you should definitely be looking into Bisco. Bisco is a great company that has an unparalleled track record. I can unequivocally say... is their passion. They are genuinely dedicated to understanding and improving the ability to bond dental restorations. Visco is a company that places tremendous value on research and scientific knowledge to benefit you and your practice. Being an endodontist myself, my favorite Bisco product is Theracal LC, which hands down is one of the best materials to use for direct and indirect pulp capping procedures. It not only seals the dentin, but offers significant calcium release, which stimulates hydroxyapatite and secondary bridge formation, which is exactly what we're looking for in these kind of procedures. So check out their entire product line of premium adhesive products at bisco.com. Well, I think the most important thing for any practice is having team meetings and having this be the focus of a team meeting. how you want to lead it. I think it's so important. It's just as important as all the other screenings that we do. And so again, having a team meeting that you all agree on what the protocol looks like and you're all doing it the same way. So the patient's experiencing it the same way and being talked to the same way because communication is always important too. You know, you don't want to scare a patient. You want to elevate the patient's awareness. You want to elevate. um the service that you're providing to them and you want them to know that you know you might be doing something different than the the practice down the street so it's a great opportunity to to share that with your patients and why you're doing it not to scare them but just come from the place of empathy and and we care about you because that's really the that's that's really what it's about and we want to prevent we don't want to find something now we want to prevent ever finding anything So if a practice wants to ramp up their head and neck evaluations, and let's say the dentist has a hygiene department and he or she feels that that would be the best way to start, would you recommend changing the time allotment for a typical hygiene appointment for a re-care patient, considering the fact that now a head and neck evaluation would be included in that visit on a regular basis? I think everybody's scheduling is a little different. But, you know, if you're doing a 40, if you're only scheduling 45 minute hygiene, I have a problem with that. That's my opinion, unless you have an assistant that's helping you and you actually have the patient there for an hour or more. But, you know, we have a lot of tools in our toolbox and we can't do them all every single time. we should then be making a note that next time we need to offer that service. We need to offer, and I think manually and tactile, at least once a year, if not twice a year. They may have swollen lymph nodes that they didn't have the time before, and maybe they have a flare-up of HPV. How do we know if we're not feeling and we're not looking? Now that we're having this discussion, Katra, I'm curious to know how you got so passionate and involved as a hygienist. regarding early detection of cancer and working very hard to make dental practices aware that it really is their responsibility to pursue these evaluations in order to detect cancer early because we can't rely on the medical profession to do so. What made you so passionate about this? Well, you know, right out of hygiene school, my very first job was at a prosthodontic office. And back then in 93, And we weren't detecting it like we are now. And most people never received their prosthesis from the doctor I worked with. And I'll never forget a patient coming in. They wheeled her over from the hospital that we were attached to. And they wheeled her in. And I was like, oh, wow, this is going to be really cool to see. It really was as we unwired her dentures because she had lost half of her maxilla and half of her mandible. And it was super interesting to me. I mean, from a clinical standpoint, and I was really okay with watching and observing this and learning until I looked the patient in the eyes and I had to leave. And to this day, I just get choked up thinking about it because I can see, you know, I made that connection with her and I could see, wow. This is a horrible, horrible cancer. It's not one you can hide behind. You know, I could, as soon as we took out her dentures, her upper and lower interim prosthesis, her entire face collapsed. And she, you know, she didn't look the same. Cancer in general, of course, is so devastating. And these types of cancers are devastating in so many different ways, psychologically, socially, physical pain, loss of function, speech. So many factors involved with the devastation of oral cancer and what it can do to a human being. How old was this particular patient that you're talking about? You know, she looked a lot older than she was because she was so sick. I don't know. And that was long enough ago now. I've been out of hygiene school since 93. So I'm aging myself now. But, you know. It really hit home for me. And I never looked at a patient the same. And back then, like I said, we just, we weren't as thorough with our head and neck evaluations. We've learned, we've learned the hard way because so many people die from this. And it's such a leading cancer. And, you know, we've learned that we have to do more to screen. And with HPV now, that's just played a whole nother influx of oral cancers. wow, you know, we have an opportunity to save lives and we need to do it. We may need to cut out something else that's less important. I mean, what's the priority? I've always said, you know, our number one reason for a lawsuit in a dental practice was untreated, undiagnosed perio, but I can tell you oral cancer is right behind it now because it's our responsibility. It's certainly hard for me to rationalize why a dental practice would not perform at least one head and neck. oral cancer screening each year on every patient that comes into the practice. To me, that would be the minimum preventive treatment that would be performed on these patients on an annual basis. There might be an argument by the dental practice saying that they don't feel like they have the training to fully capture signs of early cancer, and therefore they don't want to give the patient the false sense of security. that they have absolutely nothing going on that's dangerous in their oral cavity and their throat. And then if the patient does develop something later down the road, they may come back to that dental office and say, you know, I was getting regular checkups. I was getting regular evaluations and they didn't see anything. It was their responsibility to catch this. And maybe that dental practice who feels like it's not in their purview and they're not trained enough to do it, they may feel that that's a reason. And just to make sure that they don't fall prey to a litigious situation where the patient comes back to that office. Now, on the flip side, you know, there's probably more liability that the dental practice is exposed to by not doing any head and neck evaluation at all and no preventative oral cancer screenings. So there's both sides there. But of course, at this point in time, I can't imagine not doing a swab of the pharynx, sending it out to a lab and regularly checking for HPV, knowing the upswing in throat cancer and using screening tools that take advantage of autofluorescence. And they can take a look at what's typically healthy tissue versus tissue that may be early signs of cancerous activity going on. Then there's the saliva test with oral DNA and so forth. So certainly we have tools. to help us along here. So I think at this point in time, no dental practice really has an excuse to say that I don't do head and neck exams or I don't screen for oral cancer because of whatever reason they have. I just don't think there's any reason that could be justified not to do it. Me either. But, you know, can we say potentially managed neglect? Isn't that what it comes down to? Neglect on the part of the dentist you're saying? Yeah, on the part of the practice, you know. And I think one of the biggest reasons is the low reimbursements on dental. They have dental practices on a hamster wheel trying to make production, hourly production. And I get that. But that's why I do what I do is to help practices get reimbursed at a better rate for all the things that we do. oral cancer screenings, advanced oral cancer screenings with a veloscope or oral ID or an HPV salivary test. Those are all things that can go to medical or an orthopanogram. Those are all things that we can do at a preventative level and build a medical. So we can make it feasible for practices to slow down and do what's right for the patient. Yeah. Could you give an example of reimbursement? for a dental practice using the medical insurance of a patient for a head and neck evaluation? The first thing they would do would be to bill the dental, for instance. And then the dental would say, well, you've already done one, or this patient doesn't have coverage for any kind of radiograph more than every three years or whatever. And then they decide to go to medical. What are we talking about as far as reimbursement using the medical insurance side? Well, reimbursement on the medical side is very different. If you look at a periodic eval, and typically I see that paid out on average about $35 if you're in network with dental. That is a benefit. And so when I say $35, it doesn't matter if you saw a patient that was 10 years old or a patient that was 80 years old. You're only reimbursed that amount for an 0120 for that periodic eval. Medicine is very different. So in that evaluation, depending on the medical decision making and the complexity of that eval, including the maxillofacial and oral cancer screening, there's other things that go into that eval, right? That, as well as the amount of time that we spent, whether it's FaceTime or non-FaceTime, is how medical pays. So it allows you to have more of a sliding scale based on the medical decision -making and the time that we spend with our patients, evaluating and diagnosing and treating. And so that's a hard thing to say. I can tell you that I have practices that are getting paid upwards of $300 for a medical evaluation out of hygiene. And how long does that take, that medical evaluation? Maybe a total of, I would have to look at my table, maybe a total of 30 minutes. You know, and again, when we say time, that's face time, non-face time. We do a lot of stuff and we evaluate a lot of things, but we don't really. tally up the time. And again, that's FaceTime and non-FaceTime. So say I'm taking x-rays in my hygiene operatory and the doctor is looking and evaluating and diagnosing from their office. That's part of the evaluation. What if they are... What if they do a PA, a PAN, and a CT? Those are three different evaluations going on with three different images for all different reasons. That's part of the complexity. I mean, there's so many things involved in an eval that we just don't give ourselves credit for. There's no comparison to an 0120 reimbursement compared to medical because we're actually reimbursed for our time and our medical decision -making. So there are several take-home messages, Kandra, from talking to you in this podcast. For sure, it's our responsibility as a dental professional to keep the patient safe, doing whatever we can do in terms of preventing the progression of cancer. So early detection is so important. It saves lives. That's number one. Number two, we have to look at it as something that we have to schedule for in our regular re-care appointments where we're prepared to take the time to at least do a manual and a tactile exam to check for any type of lymphadenopathy or anything changing in the oral cavity, the throat, the neck area. Visuals using autofluorescence is certainly a big help. And then you mentioned saliva tests, oral ID, and so forth. So these are all things we could do. But the other big thing is that these patients have medical insurance and we shouldn't be bound by the restrictions of dental insurance companies. And certainly these exams can be transferred over to the patient's medical insurance, which in many cases can generate as much as $300 for 30 minutes of the practice's time. So this is a big win-win for the patient in the practice. The patient gets regular. and more consistent early detection exams, head and neck evaluations, and the doctor gets paid for it commensurately, and everybody's happy, and it can save a lot of lives. Now, you have a company that specializes in training dental practices on all the nuances of getting paid through a patient's medical insurance, which many front desk people and back office billing staff are not comfortable with. They're not familiar with it. train these offices to do all this and you get great results, multiple return on investment as far as what the cost is to be part of your organization or to work with your organization. You also have a free assessment and a website. So tell us about the free assessment. Sure. So I offer a complimentary medical billing analysis, an MBA. And basically I take your practice numbers over the last 12 months, evaluate. and show you what opportunities I see. You know, how many things are we giving away that we're not being reimbursed for because we know that the patient is maxed out on their dental benefits or their dental benefits doesn't pay for it at all. So we write it off. Like, I just try to give you a really good snapshot of the opportunities, not only from a fee schedule standpoint, but all the things, again, that we're potentially writing off and just giving away because we're... We're brainwashed by this thing called dental benefits. That's one way to look at it. Let's hope the insurance companies aren't listening to this podcast. We appreciate your time. We appreciate your insight. And thank you so much. Again, if you want to get a hold of Kandra, visit TIPS Medical Billing and check out what they have to offer. And we look forward to having you on future programs, Kandra. Thank you. Thank you so much. 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.