Insurance is the patient’s responsibility. It is their insurance after all however, quickly and accurately verifying insurance is an opportunity to provide patients with excellent customer service. 

Staying on top of insurance every day is crucial. It is vital that insurance does not backlog. Backlogs cost you time and money and reflect poorly on your practice. 

When a patient receives a bill from the practice due to insurance denial it can cause an upset. Sometimes it is a front desk error, however the upset is often partially or fully due to the bill being unexpected because the patient had not been effectively educated on how dental benefits work. 

By following this protocol your patients will be prepared. They may not be happy about a bill should they get one but, they will be more likely to blame their provider than you.

Before Patients Are Seen

1. Benefits change. Keep PPO fee schedules up to date in your practice management software. 
2. Real Time Eligibility is widely available, saves time and increases accuracy. 
3. Accurate and complete patient insurance info is vital otherwise you cannot verify accurately.
4. Always verify a new patient’s benefits before they arrive. The new patient should be called prior to their arrival with what to expect as far as their co-pay. 
5. Update benefits prior to existing patient appointments.
6. The Treatment Coordinator re-enforces the clinical education the patient received in the back, creates an honest sense of urgency to make financial arrangements and scheduling smoother but, first the Treatment Coordinator needs to educate the patient on how dental insurancebenefits work including details of the patient’s specific plan. Key points to go over with all patients:

 Dental insurancebenefits can be compared to a “gift card” from Target or Best Buy. You need a new cell phone that costs $1,000.00. You have a gift card worth $100.00. Guess who pays the difference?

Patients need to know insurance companies are not exactly their friends as insurance companies frequently deny claims. The patient should also know the patient’s benefits are not negotiated by your practice. They are typically negotiated by the patient’s employer.

The Treatment Coordinator should make known to the patient any restrictions, such as frequency limitations, etc.Going over the patient’s verified benefits helps avoid unexpected news for the patient later on.

You are the patient’s insurance advocate so to speak.It is you plus the patient against the insurance company. Let the patient know the way you advocate for them is to educate them on how their dental benefits work and to submit the claim completely and accurately. If the claim is denied you will send an appeal but, at the end of the day, if the patient’s insurance company refuses to pay, the patient is responsible for the balance. 

Ensure all patients sign their treatment plan and your financial policy and that the patient receives copies of each. 

7. A “Co-Pay Estimate” is different than a “Pre- Determination” or “Pre-Treatment Estimate”. 

A “Co-Pay Estimate” is generated by the practice. 

A “Pre- Determination” or “Pre-Treatment Estimate” is generated by the insurance compant and is NOT a guarantee of payment as insurance companies often “change their minds”.

Do not offer a “Pre- Determination” or “Pre-Treatment Estimate”. If the patient requests one, that is fine but, then schedule the patient far enough out (not too far) to give enough time to receive the “Pre- Determination” or “Pre-Treatment Estimate” back from the provider. 

8. For existing patients, when they come in, ask for any change in their insurance. If changed, verify. 
9. The morning huddle should include a review of the day’s patients to ensure benefits have been verified. 
10. File claims the day of the procedure along with all required documentation. You do not want to backlog claims. Unfiled claims can quickly pile up increasing the probability of denial due to time limitations. It is also very poor customer service. 
11. Follow up on claims. With electronic filing many offices follow up after 20 days. Never go more than 30 days without following up. 80% of claims should be collected within 30 days. 95% within 90 days. 
12. Employee accountability is vital. Assign insurance to a specific employee otherwise you will have no accountability. 
13. If you have any large companies in your drawing area, group patients by the company. 
14. Track outstanding claims on a weekly basis. Daily is even better and highly recommended. 
15. Resubmit denied claims after proper research. 
16. Every month, send accurate statements but, only to patients with balances. Make sure pending claims are noted. 

When Patient Are Seen

1. Ensure needed documentation is included with claims (narratives, images, etc.) when required (restorative, perio, implants, endo, dentures, etc.). Send claims and documentation electronically. Doing so is a huge time saver. 
2. Double or triple check all codes so you don’t mistakenly use an old code. Use the latest edition of “Coding With Confidence” by Dr. Charles Blair. 
3. If code history is required (D4910 as an example), be sure to include. 
4. When submitting a claim double and triple check to ensure all information is correct. If you don’t, you substantially increase the probability of a denial wasting valuable time and energy. 

After the Patient Leaves

1. Track claims EVERY day. Your PMS will produce up-to-date reports if you have real-time access. If not, you can get the needed reports from each providers web site. 
2. Review daily:
3. Clearinghouse Claim Submission Report: Can give you an early warning if attachments are required or if claims have been denied so you quickly get the claim fixed and resubmitted which is excellent customer service.
4. Unsubmitted Claims Report. Complete and submit ASAP.
5. Review weekly or daily: Insurance Aging Report. Providers have different deadlines. Always work on the oldest first. The clock is ticking. 
6. Get educated on how appeals work for each provider. Verify adjustments. Fight for your patient as you would want someone to fight for you if they were processing your insurance. See if you can determine if there is a fix to get claim approved such as:
7. Deleted codes
8. Codes requiring history 
9. Overuse of codes 
10. Omitted documentation/images
11. Contract provision 
12. Missing tooth clause 
13. Frequency 
14. Wait periods 
15. Maximums 
16. Preventive deductibles

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    Kevin Tighe, Cambridge Dental Consultants, Senior Consultant, got bitten hard by the business and marketing bug during long summer days working at his dad's Madison Avenue ad agency. After joining Cambridge as a speaker in the mid-1990s, Kevin went on to become Cambridge’s senior consultant and eventually CEO. Cambridge Dental Consultants is a full-service dental practice management company offering customized dental office manuals. Frustrated? High overhead? Schedule a chat with Kevin at