The very short version of my 7 basic keys to reimbursement success.

1. www.LIMOLI.com
800-344-2633

2. 1924-2006

5. National Association of
Dental Plans © 2013
“The size of the dental
benefits market can be
reliably estimated at 176
million lives – or 57% of the
US population”

6. What Kind Of Coverage
Do They Have?

7. 176 Million Lives
By Plan Type
PPO
HMO
Traditional
Discount

8. Where’s The Money?

9. Usual Fee
The fee that an individual dentist
most frequently charges for a
given dental service

10. Customary Fee
The fee level determined by the
administrator of a dental benefit plan
from actual submitted fees for a
specific dental procedure to establish
the maximum benefits payable under
a given plan for that specific
procedure.

11. Reasonable Fee
The fee charged by a dentist for a
specific dental procedure that has
been modified by the nature and
severity of the condition being treated
and by any medical or dental
complication or unusual
circumstances.

12. It’s The Individual Plan,
Not The Insurance Company

13. Coding and
Reimbursement
Management is Simple
Follow Tom’s
Seven Keys to
Reimbursement Success

14. Rule 1
Diagnose and document
prior to initiating any
treatment

15. Evaluations
The codes in this section have been revised
to recognize the cognitive skills necessary
for patient evaluation. The collection and
recording of some data and components
of the dental examination may be
delegated; however, the
evaluation, diagnosis and treatment
planning are the responsibility of the
dentist.

16. Evaluations
As with all ADA procedure codes, there is no
distinction made between the evaluations
provided by general practitioners and
specialists. Report additional diagnostic
and/or definitive procedures separately.

17. Evaluations
• D0120 periodic
• D0140 limited
• D0145 under 3 years of age
• D0150 comprehensive
• D0160 detailed and extensive,
–by report
• D0170 re-evaluation – limited
• D0180 comprehensive periodontal

18. Periodic Oral Evaluation
An evaluation performed on a patient of
record to determine any changes in
the patient’s dental and medical
health status since a previous
comprehensive or periodic evaluation.

19. with CDT-7 was added
This includes an oral cancer
evaluation and periodontal
screening where indicated, and
may require interpretation of
information acquired through
additional diagnostic procedures.
Report additional diagnostic
procedures separately.

20. Limited Oral Evaluation
An evaluation limited to a specific oral
health problem. This may require
interpretation of information acquired
through additional diagnostic
procedures.

21. Problem Focused
Typically, patients receiving this type of
evaluation have been referred for a
specific problem and/or present with
dental emergencies, trauma, acute
infections, etc..

22. Comprehensive Oral
Evaluation
Used by a general dentist and/or a
specialist when evaluating a patient
comprehensively. It is a thorough
evaluation and recording of the
extraoral and intraoral hard and soft
tissues.

23. Comprehensive
This includes an evaluation for oral
cancer where indicated, the
evaluation and recording of the
patient’s dental and medical history
and a general health assessment.

24. Comprehensive
It may include the evaluation and
recording of dental caries, missing or
unerupted teeth, restorations, existing
prostheses, occlusal
relationships, periodontal conditions
(including periodontal charting), hard
and soft tissue anomalies, etc.

25. Detailed and Extensive
A detailed and extensive problem-
focused evaluation entails extensive
diagnostic and cognitive modalities
based on the findings of a
comprehensive oral evaluation.

26. Detailed and Extensive
Integration of more extensive
diagnostic modalities to develop a
treatment plan for a specific problem
is required. The condition requiring
this type of evaluation should be
described and documented.

27. Problem focused, by report
Examples of conditions requiring this type of
evaluation may include dentofacial
anomalies, complicated perio-prosthetic
conditions, complex temporomandibular
dysfunction, facial pain of unknown
origin, severe systemic diseases requiring
multi-disciplinary consultation, etc..

28. Comprehensive Periodontal
Evaluation
New or established patients
showing signs or symptoms of
periodontal disease and for the
patients with risk factors such
as smoking or diabetes.

29. D0180
It includes evaluation of periodontal
conditions, probing and charting,
evaluation and recording of the
patient’s dental and medical
history and general health
assessment.

30. D0180
It may include the evaluation and
recording of dental
caries, missing or unerupted
teeth, restorations, occlusal
relationships and oral cancer
evaluation.

31. How Often Can I Charge
For A New
Comprehensive
Evaluation?
How about the new or established
patient?

32. To Reach A Documented
Conclusion or Diagnosis

33. Limoli’s Trilogy of Reimbursement

34. Limoli’s
6 R’s
of Record-Keeping

35. 1. Reason
• Why is the patient here today?

36. 2. Review
• What is the patient’s overall
health status today?
• Evaluation of the patient’s dental
needs and description of
condition

37. 3. Radiographs
• Are radiographs needed?
• Why are they being taken?
• Document what they show.

38. 4. Recommended Treatment
• Based upon the evaluation and
diagnosis, what treatment is
recommended by the dentist?

39. 5. Rendered Treatment
• What procedures were
performed?
• What anesthesia was used?
• Other materials used?

40. 6. Response to Treatment
• How did the patient’s condition
respond to treatment?
• What are the next steps or
follow-up procedures?

42. Rule 2
Establish a written
treatment plan for the
patient as well as
yourself

43. Report of findings
• What is the patient’s chief
concern?
• What is good?
• What needs to be improved?
• What needs to be replaced?

44. Peter E. Dawson, DDS
“The prime requirement of
good treatment planning
is to do the minimum
required to achieve
optimum oral health”

45. Slow Down

46. Four phases
• Allow for a triage of patient needs
• Initiate saving as many teeth as
possible
• Begin when the demand for
restorative dentistry tapers off
• Only be practiced when the patient
can demonstrate meticulous home
care

47. Phase 1
• Emergency relief of pain (D9110), routine
extractions (D7140)
• Comprehensive evaluation, radiographs
and diagnostic casts as needed
• Home care instructions (D1330)
demonstrated and evaluated
• Initial perio therapy (D4341 D4342)
• Periodontal maintenance (D4910)

48. Phase 2
• Periodontal, osseous, and mucogingival
surgery, per tooth, as prerequisite for
restorative care
• Restorative dentistry – amalgams / resins
• Endodontic
• Complicated, non-emergency extractions
(D7210 to D7241)
• Relines and repairs to existing dentures and
removable partials

49. Phase 3
• Space maintainers for children;
preventive orthodontics
• Single crowns, inlays, inlays w/
onlays
• New full dentures

50. Phase 4
• Periodontal, osseous and
mucogingival surgery, per
quadrant
• New partial dentures
• New fixed partial dentures
• Orthodontic care

51. With All Patients
A maintenance level is
achieved first, with
shared patient
responsibility, before
EXPENSIVE and
EXTENSIVE restorative
care is undertaken

52. Peter E. Dawson, DDS
“Any dentist who makes mouths
healthy and keeps them that way is
practicing complete dentistry.
Furthermore, in providing optimum
maintainability, the bonus side effects
of better comfort, function, and even
esthetics are more easily achieved.”

53. Rule 3
Secure financial
arrangements prior to
treatment

54. Who Pays What Amount To
Whom
Follow the money and you enforce
the accountability

55. Assignment of Benefit is
a two edged sword

56. What is a write off?

57. “You cannot lose that which you
never had”

58. In other words
• If your usual fee is $800
• And, the plans maximum allowance is only
$600
• You did not lose $200 doing the
procedures?
• You cannot lose that which you never had
in the first place

59. Schedule by production
• Production is a measurement in
dollars of the actual services
performed.
• Current production figures gain
meaning as they are compared to
those of the same period last year
• Not a financial number because it
only represents a potential number

60. Schedule by collection
• This figure is the total of all monies
received by the practice during a
specific period.
• Collections are a measurement of the
effectiveness of the practice’s credit
policy and those responsible for its
execution.

61. Rule 4
Patient must acknowledge
and agree to pay the
total fee prior to
insurance consideration

62. Financial Arrangements
(Total Cost of Care)
vs
Benefits Assessment
(Insurance)

63. It’s the patient’s plan

64. Plan Provisions
• Reimbursement Percentile
• Alternate Benefit
• Coordination of Benefit
• Maintenance of Benefit
• Non duplication of Benefit
• Date of Incurred Liability
• Birthday Rule
• Predetermination

65. Benefit Plan Provisions
Must Be Confirmed With
Each New Series Of
Visits

66. Your office must follow the
benefit plan provisions.
Providership is not a
consideration or excuse.

68. Secure Specifics In
Writing From The Plan
Or Make Other Financial
Arrangements.
Get The Benefit Booklet From
The Patient – The www or Fax
Back

69. Always Confirm Eligibility With
Each Appointment
If you file the claim,
it’s your responsibility

70. Eligibility
• Benefit Card
• Call the day of the patient visit
• Reference #
• Name of contact
• Don’t forget the employer
• Web based plan access

71. But what fee goes
on the claim form?
Your full “USUAL” fee
We will talk about
discounts later

72. Alternate Benefit
A provision in a dental plan contract
that allows the third-party payer to
determine the benefits based on
an alternate procedure that is
generally less expensive than the
one provided or proposed

73. with alternate benefit
The plan is not dictating
treatment, they are only
determining coverage based
upon that plans specific
contract language

74. Why the plan does not
pay?
Exclusions, limitations and
carve outs of coverage

75. Coordination of Benefits
• A method of integrating benefits
payable under more than one plan
• The benefit plans work together
• Benefits from all sources do not
exceed 100% of the total charge

76. Maintenance of Benefits
• A method of restricting benefits
payable under more than one plan
• Secondary plan pays no more than if
it were primary
• If primary plan pays, secondary plan
does not

77. Nonduplication of Benefits
• A method of restricting benefits
payable under more than one plan
• If primary plan pays, secondary plan
does not
• If primary plan does not pay,
secondary plan may/may not

78. The Problem
Elimination and/or reduction of
secondary coverage's
although premiums paid by
both primary and secondary
beneficiaries

79. The Solution
• Don’t accept authorization for
payment on secondary coverage
• Have the plan reimburse the patient
• Financial arrangements based on
primary coverage

80. Rules of Primacy
• The plan covering the patient as
anything other than a dependent is
primary
• The plan without a COB provision is
primary
• Lowest dollar threshold is primary

81. What is the date of
incurred liability

82. Limoli says to always:
“Wait to Generate the
Claim Until the
Treatment Procedure
is Completed”

83. Assignment of Benefits
A procedure whereby a beneficiary
authorizes the administrator of the
program to forward payment for
covered procedures directly to the
treating dentist.

84. Assignment of
Benefits is not an
Authorization for
Payment

85. Preauthorization
Precertification
Predetermination
Prior Authorization

86. simply defined as:
an indication of the dollar
amount to be paid for covered
services contingent upon
continuing eligibility

87. First Instance
Important for the patient to know
approximately how much their dental
benefit plan may pay.
Determines full cost of treatment before
treatment is actually started.

88. Second Instance
Since we have no record of having
received a predetermination…
Treatment plan exceeded $250
Benefits are payable for only
diagnostic, preventive and palliative
services

89. Third Instance
Uncooperative patient with no printed
benefit information
“I have insurance and my husband has
insurance. Everything is paid at 100%
in full”

90. Never a guarantee of
reimbursement
You can’t take it to the
bank

91. Discounts
• Total Fee Charged (Question 53) must be
the fee you intend to collect.
• It is illegal to discount based on the
patients co-payment.
• Discount must be disclosed when the
claim is filed.

92. Rule 5
Bill and code for exactly
what dated services are
rendered

93. Current Dental
Terminology
The Code on Dental
Procedures and
Nomenclature

94. We Have More Code
Changes on the Way

96. Let’s Do Some Claims

97. Doctor
Diagnosis
Clinical
Findings
Narrative /
Attachment
Code

99. •No attachment loss
•No bone loss
•Abundance of
plaque, calculus and
stain
“Last professional
cleaning was 24
months ago”
D1110 Prophylaxis

100. Prophylaxis - Adult
A dental prophylaxis performed on
transitional or permanent dentition
which includes scaling and
polishing procedures to remove
plaque, calculus and stains.
“coronal” deleted with CDT-2005

101. with CDT-2005
Descriptor changed to removal
of plaque, calculus and stain
from the tooth structure…
As well as local irritational
factors…

102. Non-Surgical
Periodontal Service
• D4355 full mouth debridement to
enable comprehensive evaluation
and diagnosis

103. D4355
• The gross removal of plaque
and calculus that interfere with
the ability of the dentist to
perform a comprehensive oral
evaluation.
• This preliminary procedure
does not preclude the need for
additional procedures.

104. D4355
When an
evaluation, diagnosis
and radiographs are not
possible.
Not a routine procedure

105. Other Periodontal
Services
• D4910 periodontal maintenance
procedures (following active therapy)
This procedure is for patients who have
previously been treated for
periodontal disease.

106. D4910
This procedure is instituted following
periodontal therapy and continues at
varying intervals, determined by the
clinical evaluation of the dentist, for
the life of the dentition or any implant
replacement.

107. D4910 Includes
• Removal of the bacterial plaque and
calculus from supragingival and
subgingival regions
• Site specific scaling and root planing
where indicated (D4341 or D4342)
and
• polishing of the teeth (D1110).

108. •What about the
evaluation?
•Is it charged out
separately?
• Can the hygienist do the
evaluation?

109. “Periodic maintenance
treatment following
periodontal therapy is
not synonymous with a
prophylaxis”

110. Never alternate
D4910 with D1110

111. Sequential Order of
Treatment
• Diagnose First
• Treat based on diagnosis
• Evaluate treatment
• Continue treatment
• Continue evaluation

112. Rule 6
What the insurance does
not pay - the patient
must pay

113. Dental Benefit Plan
Any plan is simply a device
which those individuals in
the work force are using to
help offset the cost of dental
care

114. Fee For Service
Dentistry
With A Managed
Care Component

115. “If you are thinking a year
ahead, sow seed. If you
are thinking ten years
ahead, plant a tree. If
you are thinking one
hundred years
ahead, educate the
people.”

116. Managed care will not
solve the
inadequacies of a
low-
profit, mismanaged
dental practice.

117. Look closely at your
existing patient base and
bank deposit, then
determine:
How insurance dependent
is your dental practice?

118. Track the third-party
portion of your bank
deposit by payer
and employer.

119. If a major employer in
your area is involved
with a substantial
portion of your
practice
revenues, monitor that
employer base
closely.

120. Don’t Speak Poorly Of The
Employer and Benefit Plan

121. “Fee For Service”
selling procedures for a
fee
“Service For A Fee”
managed care selling
time

122. We must maintain
our posture of
serving the needs
(both clinical and
financial) of our
patient base.

123. “I would never
have guessed in
a million years
that my patients
would leave me
for a dollar”

124. What’s good for
Managed Care can
be great in
Fee-For-Service
Limoli & Associates

125. But if its not for you, simply get out
of the plan

126. You Must Stop Accepting
Assignments of Benefits

127. The Patient Must Be Accountable
For The Strengths And
Weaknesses Of Their Own
Benefit Plan

128. Rule 7
If the patient does not pay
- hunt them down like
you would a rabid dog