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

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

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7 keys 2013 webinar only Presentation Transcript

  • 1. www.LIMOLI.com 800-344-2633
  • 2. 1924-2006
  • 3. 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”
  • 4. What Kind Of Coverage Do They Have?
  • 5. 176 Million Lives By Plan Type PPO HMO Traditional Discount
  • 6. Where’s The Money?
  • 7. Usual Fee The fee that an individual dentist most frequently charges for a given dental service
  • 8. 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.
  • 9. 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.
  • 10. It’s The Individual Plan, Not The Insurance Company
  • 11. Coding and Reimbursement Management is Simple Follow Tom’s Seven Keys to Reimbursement Success
  • 12. Rule 1 Diagnose and document prior to initiating any treatment
  • 13. 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.
  • 14. 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.
  • 15. 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
  • 16. 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.
  • 17. 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.
  • 18. Limited Oral Evaluation An evaluation limited to a specific oral health problem. This may require interpretation of information acquired through additional diagnostic procedures.
  • 19. 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..
  • 20. 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.
  • 21. 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.
  • 22. 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.
  • 23. 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.
  • 24. 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.
  • 25. 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..
  • 26. 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.
  • 27. 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.
  • 28. D0180 It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships and oral cancer evaluation.
  • 29. How Often Can I Charge For A New Comprehensive Evaluation? How about the new or established patient?
  • 30. To Reach A Documented Conclusion or Diagnosis
  • 31. Limoli’s Trilogy of Reimbursement
  • 32. Limoli’s 6 R’s of Record-Keeping
  • 33. 1. Reason • Why is the patient here today?
  • 34. 2. Review • What is the patient’s overall health status today? • Evaluation of the patient’s dental needs and description of condition
  • 35. 3. Radiographs • Are radiographs needed? • Why are they being taken? • Document what they show.
  • 36. 4. Recommended Treatment • Based upon the evaluation and diagnosis, what treatment is recommended by the dentist?
  • 37. 5. Rendered Treatment • What procedures were performed? • What anesthesia was used? • Other materials used?
  • 38. 6. Response to Treatment • How did the patient’s condition respond to treatment? • What are the next steps or follow-up procedures?
  • 39. Rule 2 Establish a written treatment plan for the patient as well as yourself
  • 40. Report of findings • What is the patient’s chief concern? • What is good? • What needs to be improved? • What needs to be replaced?
  • 41. Peter E. Dawson, DDS “The prime requirement of good treatment planning is to do the minimum required to achieve optimum oral health”
  • 42. Slow Down
  • 43. 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
  • 44. 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)
  • 45. 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
  • 46. Phase 3 • Space maintainers for children; preventive orthodontics • Single crowns, inlays, inlays w/ onlays • New full dentures
  • 47. Phase 4 • Periodontal, osseous and mucogingival surgery, per quadrant • New partial dentures • New fixed partial dentures • Orthodontic care
  • 48. With All Patients A maintenance level is achieved first, with shared patient responsibility, before EXPENSIVE and EXTENSIVE restorative care is undertaken
  • 49. 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.”
  • 50. Rule 3 Secure financial arrangements prior to treatment
  • 51. Who Pays What Amount To Whom Follow the money and you enforce the accountability
  • 52. Assignment of Benefit is a two edged sword
  • 53. What is a write off?
  • 54. “You cannot lose that which you never had”
  • 55. 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
  • 56. 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
  • 57. 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.
  • 58. Rule 4 Patient must acknowledge and agree to pay the total fee prior to insurance consideration
  • 59. Financial Arrangements (Total Cost of Care) vs Benefits Assessment (Insurance)
  • 60. It’s the patient’s plan
  • 61. Plan Provisions • Reimbursement Percentile • Alternate Benefit • Coordination of Benefit • Maintenance of Benefit • Non duplication of Benefit • Date of Incurred Liability • Birthday Rule • Predetermination
  • 62. Benefit Plan Provisions Must Be Confirmed With Each New Series Of Visits
  • 63. Your office must follow the benefit plan provisions. Providership is not a consideration or excuse.
  • 64. Secure Specifics In Writing From The Plan Or Make Other Financial Arrangements. Get The Benefit Booklet From The Patient – The www or Fax Back
  • 65. Always Confirm Eligibility With Each Appointment If you file the claim, it’s your responsibility
  • 66. Eligibility • Benefit Card • Call the day of the patient visit • Reference # • Name of contact • Don’t forget the employer • Web based plan access
  • 67. But what fee goes on the claim form? Your full “USUAL” fee We will talk about discounts later
  • 68. 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
  • 69. with alternate benefit The plan is not dictating treatment, they are only determining coverage based upon that plans specific contract language
  • 70. Why the plan does not pay? Exclusions, limitations and carve outs of coverage
  • 71. 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
  • 72. 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
  • 73. 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
  • 74. The Problem Elimination and/or reduction of secondary coverage's although premiums paid by both primary and secondary beneficiaries
  • 75. The Solution • Don’t accept authorization for payment on secondary coverage • Have the plan reimburse the patient • Financial arrangements based on primary coverage
  • 76. 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
  • 77. What is the date of incurred liability
  • 78. Limoli says to always: “Wait to Generate the Claim Until the Treatment Procedure is Completed”
  • 79. 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.
  • 80. Assignment of Benefits is not an Authorization for Payment
  • 81. Preauthorization Precertification Predetermination Prior Authorization
  • 82. simply defined as: an indication of the dollar amount to be paid for covered services contingent upon continuing eligibility
  • 83. 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.
  • 84. 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
  • 85. Third Instance Uncooperative patient with no printed benefit information “I have insurance and my husband has insurance. Everything is paid at 100% in full”
  • 86. Never a guarantee of reimbursement You can’t take it to the bank
  • 87. 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.
  • 88. Rule 5 Bill and code for exactly what dated services are rendered
  • 89. Current Dental Terminology The Code on Dental Procedures and Nomenclature
  • 90. We Have More Code Changes on the Way
  • 91. Let’s Do Some Claims
  • 92. Doctor Diagnosis Clinical Findings Narrative / Attachment Code
  • 93. •No attachment loss •No bone loss •Abundance of plaque, calculus and stain “Last professional cleaning was 24 months ago” D1110 Prophylaxis
  • 94. 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
  • 95. with CDT-2005 Descriptor changed to removal of plaque, calculus and stain from the tooth structure… As well as local irritational factors…
  • 96. Non-Surgical Periodontal Service • D4355 full mouth debridement to enable comprehensive evaluation and diagnosis
  • 97. 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.
  • 98. D4355 When an evaluation, diagnosis and radiographs are not possible. Not a routine procedure
  • 99. Other Periodontal Services • D4910 periodontal maintenance procedures (following active therapy) This procedure is for patients who have previously been treated for periodontal disease.
  • 100. 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.
  • 101. 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).
  • 102. •What about the evaluation? •Is it charged out separately? • Can the hygienist do the evaluation?
  • 103. “Periodic maintenance treatment following periodontal therapy is not synonymous with a prophylaxis”
  • 104. Never alternate D4910 with D1110
  • 105. Sequential Order of Treatment • Diagnose First • Treat based on diagnosis • Evaluate treatment • Continue treatment • Continue evaluation
  • 106. Rule 6 What the insurance does not pay - the patient must pay
  • 107. 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
  • 108. Fee For Service Dentistry With A Managed Care Component
  • 109. “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.”
  • 110. Managed care will not solve the inadequacies of a low- profit, mismanaged dental practice.
  • 111. Look closely at your existing patient base and bank deposit, then determine: How insurance dependent is your dental practice?
  • 112. Track the third-party portion of your bank deposit by payer and employer.
  • 113. If a major employer in your area is involved with a substantial portion of your practice revenues, monitor that employer base closely.
  • 114. Don’t Speak Poorly Of The Employer and Benefit Plan
  • 115. “Fee For Service” selling procedures for a fee “Service For A Fee” managed care selling time
  • 116. We must maintain our posture of serving the needs (both clinical and financial) of our patient base.
  • 117. “I would never have guessed in a million years that my patients would leave me for a dollar”
  • 118. What’s good for Managed Care can be great in Fee-For-Service Limoli & Associates
  • 119. But if its not for you, simply get out of the plan
  • 120. You Must Stop Accepting Assignments of Benefits
  • 121. The Patient Must Be Accountable For The Strengths And Weaknesses Of Their Own Benefit Plan
  • 122. Rule 7 If the patient does not pay - hunt them down like you would a rabid dog