First, let's cover what a downgrade is. A downgrade or dental insurance downgrade occurs when insurance companies elect to pay for the least expensive procedure if there is more than one acceptable option. In this situation, the patient can receive any treatment but if they elect for the more expensive (non-covered option) they will have an increase in out of pocket portion. Filings and crowns are often downgraded. What is a posterior downgrade? Let's say a patient has a traditional 100/80/50 plan and fillings are covered 80%. However, the insurance company downgrades on posterior teeth to an amalgam restoration. $100 Posterior Composite $ 80 Amalgam Composite Since the benefit is the amalgam, the insurance coverage is $64.The patient will pay $36. Even though they have 80% coverage, we must factor the coverage on the allowable fee of the Amalgam Composite. Can I charge a patient the difference for a downgrade? YES. You are allowed to charge the difference to the patient. Are insurances allowed to downgrade procedures even if we are out of network? YES! It does not matter if a dental office is in or out of network. The provisions of each plan are governed by the insurance. In network status does not determine if downgrades apply to a patient. How do I get my dental software to factor downgrades in a treatment plan? Check to see if your dental software has a payment table. This may be called something different in your software. However, if you have this it would be an area that allows you to type in the actual payment you will receive from the insurance company. This is not to be mistaken for the fee schedule. When you find a patient has a downgrade, simply change the payment to the amount expected for the downgraded procedure. Example: Expected reimbursement: $80 for a composite filling $64 for a amalgam filling Add an entry to your payment table for the composite filling to be $64. This will generate a proper patient copay when you generate the treatment plan. My old office manager said when there is a downgrade, just change the percentage for the downgraded procedure by 10%, is that right? No, Nope, Not at all, Don't Listen.... I have seen this about 1,892,362 times and it drives me insane. Do not, I repeat, do not change the percentage of coverage for downgrades. That is not how it works. The insurance pays a percent for that service. They are not telling you that they pay a different percentage, they are saying we pay a different fee. Always go back to the procedure they are downgrading, find the fee then multiply the % so you can get the actual reimbursement. Update your payment table so you do not have to figure this on every patient in that same group. How do I explain to a patient they have a downgrade but they still need to have the treatment? [Insert Insurance Company Name] provides what is called an alternate benefit for [insert treatment diagnosed]. Your copay is $______. Our thought is "why make a big deal out of something that does not have to be a big deal?" A lot of sentences just become a lot of sentences. Say what it is and what their cost is. If you dig too deep, you will meet objection and may risk completing treatment. If the patient asks questions, explain the risks associated and your best practices. It starts with knowing the patients desires, fears and reason for wanting you to take care of them. Uncover what is important to them and this conversation will not be as difficult as you think.

Sometimes we need to see from a different vantage point. Are you billing out for the D9986 or D9987? Have you talked with your team about it? Do you accept Medicaid? Do you accept PPO plans? Do you charge missed appointment fees? So many questions. So many things to ponderWhen all dental offices start billing dental insurance for ALL the things they are doing, we will see traction like you cannot imagine.  I know this sounds crazy but consistency is everything. Make a habit out of how you bill Dental Insurance. If you bill for missed appointments, bill this on every claim to every dental insurance. We are seeing about 5%-15% of all of our D9986 and D9987 being paid.  Yes, we bill a lot of these so that number is little, right now.  When insurances see more and more claim submissions for codes, these go into consideration for future eligible covered services. Do not forget why you should be paid for every service.  Do not be jaded by what a past Office Manager or "expert biller" tells you.  When in doubt, bill it out. Last but not least, if you accept Medicaid or Medicare, your patients missing their appointments can disqualify them for coverage.  Report habitual offenders and save your dental practice time and money. Yes, we advocate for the patient, yes, we believe every patient deserves the best patient care possible but we also know that Dental Offices all over the United States are consumed with at least 2-10 missed appointments per week (more depending on the volume).  What if you received $50 for just one of those each month from an insurance company? This would mean $600/year. Think about it. Questions, please email me directly, sarahbeth@dentistrysupport.com

Your Dental Hygiene Billing Questions Answered 1. Why are dental insurance companies allowed to change the dental codes we submit to them? I think this question might be talking about third-party payer remapping (down-coding) of dental claim submissions. The interesting thing here ... dental insurance policies actually determine if codes can be changed, not the dentist or provider. Crazy, huh? So, yep, you guessed it, carriers can change a submitted code, but professionals cannot. Codes changed by a carrier are always based on the contract and money. When a professional or practice, under the professional license, changes a code for the purpose of increasing payment, it is fraud because the practice is saying it did something different than the actual treatment. 2. D4910 +/- D1110 Can we alternate these codes? Here is the skinny on this...brace yourself if your office is submitting this way....well... When an office deliberately alternates the D1110 and D4910 to maximize insurance benefits it is considered fraud. We must code for the procedure being performed. By doing otherwise, the attorney general could make a convincing case for the prosecution of an office. While codes can be changed regarding policy treatment should be based on clinical diagnosis, not on policy or coverage of benefits. 3. Help me understand the D4346 code...Can we bill this in addition to the D1110 or is it a stand-alone? The D4346 code addresses the procedure between a prophylaxis and a scaling and root planing, it is a separate procedure and not an add-on. • Localized inflammation <30% teeth = D1110/D1120 • Generalized inflammation >30% teeth = D4346 • Periodontitis = D4342/D4341 4. Can you help me with a D4355? This is a preliminary superficial removal of plaque and calculus. A D4355 is for cases where deposits are so heavy that they interfere with the ability to do a comprehensive oral evaluation. A second visit would be scheduled for an exam and diagnosis, followed by the appropriate hygiene visit(s) for definitive treatment (prophy, scaling in the presence of moderate to severe inflammation, scaling and root planing). 5. How do I explain coverage to a patient? Coverage is a contract between a third-party carrier and—most often—a patient’s, spouse’s, or parent’s employer. Some dental offices have contracts with dental benefits carriers (insurance companies). All of these are also contract negotiations. Coverage or non-coverage is based on the agreements negotiated with each of those. The dental office is merely a facilitator of filing claims and the contracts and verbiage therein determine payment. No matter how much we try, we can not ever guarantee payment. 6. How do we decide what we charge for services? A practice can choose what fees to charge. Practice fees should be based on the cost of doing business plus a reasonable profit. Often times, people think they should pull a report of the common UCR in the area. The truth is, to determine the actual Cost of Goods Sold (cogs) or Cost of Services Sold and multiply that by 3.  For example, if you pay your hygienist $40 per hour and the supplies, rent and utilities cost $15 for a 1-hour cleaning appointment your math may look something like this: $40 + $15 = $55 $55 is the COS  COS x 3 = $165 fee If the cost is too high for your area, then we must modify the time spent on the service, the cost of supplies, increase services rendered to generate more revenue or modify the cost of the staff (payroll). 7. What should I verify when asking for eligibility?  Here at Dentistry Support, we verify all insurance for all aspects of dentistry.  Here is a snippet of the preventive section of our customized Break down of Benefits form. This section is fully customized for your dental practice. For more information, feel free to email me directly at sarahbeth@dentistrysupport.com Happy to help,

Often, in management circles, I have heard the common opinion that Servant Leadership is being a pushover.  I'm here to tell you, that is not true.  As an avid believer in serving others and a proven tester of this method of leadership, I assure you, it is not a weakness. To the contrary actually. I find a weakness in those who push over others, use strong words to bring others down because they do not like something they did or even those who talk disparagingly about others behind their back. This goes for those conversations with other dentists, family members, co-workers or other subordinates... What it is...Yea, let us talk about that. It Encourages Diversity of Thought Servant leadership encourages everyone to think outside the box and considers every perspective when tasked with moving the needle forward. The final decision is the byproduct of collective collaboration and exchange of ideas. Power never rests with one person, but with everyone on the team contributing to the end result. Are you giving everyone a seat at the table? Why the heck not? It Creates a Culture of Trust Our team here at Dentistry Support can call on any of our executives or other directors and we honor them through their curiosity. So, how can executives build a higher level of trust? By being crystal clear about everything. All communications need to be specific and disseminated to every single level of the organization, top to bottom. If you are not transparent and fail to lead with a clear purpose, no one is going to follow you. Being transparent foments trust, which has a direct correlation to work performance. Remember, trust is earned, not given. Have you earned your team’s trust? It has an Unselfish Mindset It’s not about you. It never was and it never will be. It’s about the people who make it all work. Ask yourself: Where would you be without the cogs that make the engine run? One common mistake leaders make is thinking that profits and people are to be seen as separate entities when they should go hand-in-hand. You can’t have one without the other, so why keep them separate? Great hero leaders help facilitate the success of others and make everyone feel valued and their contributions matter to the overall success of the company. It Fosters Leadership in Others Fostering leadership comes in many forms, including coaching, mentorship, and growth. Take the time to teach someone the ropes, to offer words of encouragement and answer questions these young leaders have for you. Great leaders give back. Great leaders are able to put together a diverse group of people from all walks of life. In fact, diverse organizations are 1.7 times more likely to develop innovative leaders. "Great leaders are able to put together a diverse group of people from all walks of life. In fact, diverse organizations are 1.7 times more likely to develop innovative leaders'." Servant leaders give more of themselves not because they have to, but because they want to. Servant leaders are transparent, honest, and yes, even vulnerable. That sounds like it would be a weakness, but it actually can help build you up as a leader and let others see you as a human being, not just the person who signs the checks. It is infectious  Being a Servant Leader creates more servant leaders. This fills us with joy when our mission is lived out by those who we build to become more for our organizations. Oh the power we hold and on the joy we experience when our employees are able to emulate our passions, best practices and goals alike. Cheers to a great week,

It's time for us to share with you the most sought after information about Dental Insurance we hear. Many insurances (Cigna to name one) are changing the rules for preventive procedures. They are no longer being applied to maximums with PPO insurance companies. Insurance companies are paying claims within 14 days. If you are waiting until day 30 to check the status of claims, you are negatively impacting your revenue cycle. Wait for Tracer Numbers BEFORE you start posting your EFT payments. The money is not yours until a tracer number is showing int he payment (Specifically your MetLife Payments). STOP accepting Virtual Credit Cards. If you accept them, you can call the insurance company and request paper checks. You DO NOT have to pay merchant fees on those. YES, it totally pays off to have a company like this to take care of your dental insurance billing, claims research and authorization submission. (Make sure when you outsource you find a flat rate fee-based company and never go with itemized charges, % of production fees etc). Always set up your dental claim fee schedule to be the office UCR. Never set this to match the fee schedule of the insurance. (This helps increase your payments when fee schedules increase or patients have zero coverage and you are able to charge for the procedure). If you are new to billing insurance claims and you do not have a company that does this for your office, always reference the clinical note for your narrative if the dental insurance company is requesting one. D4346 is one of our favorite recommendations for hygiene billing codes. If you do not use this code, you should be talking to your hygienist about it. Another tip on codes: D9940 is an OLD CODE, stop billing for this ASAP. New Codes: 9944, 9945, 9946. Last but NOT LEAST... We beg you pretty please to STOP making up your own percentages for downgrades. When you find out a procedure is downgraded, DO NOT just change the percentage 10%, 12%, 16% or _% less than the standard coverage. This is not an accurate treatment planning. This is the proper math: Step One: Allowable Fee for the Downgraded Procedure Code x % Coverage for that category = Amount insurance will pay. Step Two: Allowable Fee of the Upgraded Procedure - Amount Insurance will pay = True Patient Copay. There is more, there is so much more but you get the gist. We LOVE OUR JOB. Like love love love it, and we want your office to know that dental insurance details are important. If you need help, let us know. We would love to join forces and support your dental practice. All my best, #dentalinsurance #dentalinsurancecompany #dentalsupport #dentaldowngrade #dentalcrown

10/31/2019 This weekend we have spent time as a team reflecting on the way we grow our leadership skills.  One great leader is Walt Disney. I have found so much inspiration from him as I look to my life, my company and my leadership. Walt Disney once said, “The greatest moments in life are not concerned with selfish achievements but rather with the things we do for the people we love and esteem, and whose respect we need.”  One of my greatest goals is to gain the respect of my team, clients, and competitors as a solidly grounded leader. To be this effective leader, we should be “passionately curious” while encouraging our employees to share ideas; something we can do by asking questions to better understand the current concerns and opportunities on our teams. This simple practice can help leaders gain the respect of the team, while also creating a collaborative environment that can help solve new or previously unsolved problems. One Disney best practice that can help leaders stay actively involved is “leader walks,” which are opportunities for leaders to be immersed with their team in the midst of the operation and to get to know their Cast Members on a more personal level. Some leaders take this a step farther, opting to periodically work a front-line shift alongside their teams in full costume. Through this type of direct experience, leaders develop a healthy respect for the work of the team, along with a greater understanding and empathy for the myriad challenges sometimes faced by the individuals in these roles. I still find it inspiring when I help my team post payments, verify eligibility or answer phones here at Dentistry Support and they are shocked.  Many of them tell me not to do the work but I love helping them. I love them trusting that I will not ever leave them alone when work gets tough, the piles stack high and support internally is needed. Do not be embarrassed as a leader that your patients or clients will think you are weak, less of a company, unworthy of business or any other degrading title.  Serving is everything.  If serving is below you, you are not ready to be a true leader. Lastly, Think about this: Does your organization encourage leaders to stay actively involved with those working the front line? Does your office know you can handle the work each of them is expected to perform? How can you more intentionally practice “management by wandering around?” Cheers to a great week, #disneyleadership #servantleadership #leadershipbyexample #unselfishmindset #dentalsupport

Your Ortho Questions Answered 1. Do I need to bill separately for an orthodontic workup? Is this a separate fee or part of the orthodontic treatment? Whether or not a separate fee is charged for an orthodontic workup or included as part of the orthodontic treatment is a business decision to be made by the dentist. 2. Does the benefit paid for an orthodontic workup always come out of the orthodontic maximum? The benefit payable for an orthodontic workup comes out of the orthodontic maximum under most patients’ contracts. 3. If a patient comes in for a visit and a panoramic film, and it is determined that the patient is too young to begin orthodontic treatment, can I charge for the visit and the panoramic film? These procedures may be submitted using the appropriate procedure codes of D8660 for the pre-orthodontic treatment visit and D0330 for the panoramic film. They will be processed according to the patient’s orthodontic benefit. 4. What code(s) should I use for an orthodontic workup? An orthodontic workup should be submitted using the appropriate CDT code for each procedure. The separate fees will be combined under CDT code D8999 and will be processed according to the patient’s orthodontic benefit, limited to the lesser of the submitted fees, filed fees, or the insurances maximum allowable charges (MAC) for each of the procedures. 5. How will an orthodontic workup be benefited if I am a general dentist rather than an orthodontist? An orthodontic workup is processed according to the patient’s orthodontic benefit whether performed by a general dentist or an orthodontist. 6. Is a second orthodontic workup covered once Phase I is completed? Orthodontic workups are processed according to the patient’s orthodontic benefit. Most plans allow one orthodontic workup for a provider for a full comprehensive orthodontic treatment plan. We always recommend billing every procedure completed because you never know when or how plans change. 7. What procedure codes should be used when there are multiple phases of treatment? Comprehensive orthodontic procedure codes should be used for multiple-phase treatment plans. Each phase is submitted as comprehensive treatment using the code that reflects the patient’s stage of dentition for that phase (transitional, adolescent or adult). 8. Do I need to send a second claim to receive additional payments? A second claim is necessary only if the patient’s orthodontic benefit is subject to a benefit year maximum. This is not the majority of cases. Most patients’ orthodontic benefits are paid according to an automatic payment schedule that does not require a second claim. The Explanation of Benefits for the initial claim will indicate if remaining benefits will be automatically generated according to a schedule. 9. What happens if a patient’s coverage is terminated during treatment? When coverage terminates during an active orthodontic treatment plan, the insurance company will prorate its payment. The number of months the patient was not eligible for coverage is deducted from the total months of treatment. Payment is based on eligible months of treatment. The payment is calculated by dividing the Insurance company's maximum liability for the entire treatment by the total months of treatment and multiplying that amount by the months of treatment during which the patient was eligible. This amount will be paid according to the orthodontic payment schedule of the patient’s plan. 10. If using clear aligners, what is needed for treatment to be considered for payment? How should it be coded? What additional information is needed? Treatment plans using clear aligners are processed according to the patient’s contract. They may be denied, or an optional benefit may be provided for conventional therapy, subject to all contract limitations and maximums for the conventional therapy. There is no unique procedure code for clear aligners; use the same procedure codes as for conventional treatment. Claims need to indicate that clear aligners are being used and must provide the same information as required for conventional treatment plans. Also, indicate any additional charges over and above your usual fee for conventional treatment, if applicable. The additional charges for these procedures are the responsibility of the patient under most patients’ plans. 11. If the patient is covered by dental insurance, but the patient has no orthodontic coverage, do I need to submit a claim form? Dentists should always submit a claim for all treatment performed on a patient, whether or not the particular service is covered so that the patient’s history is complete and so that an Explanation of Benefits can be provided indicating the patient’s responsibility for the treatment. The patient may need this for circumstances such as Coordination of Benefits or Flexible Spending Account reimbursement. 12. What happens if a patient has excessive breakage or needs to continually come into the office? Can I charge an additional fee? Will an additional benefit be payable? When submitting claims, any case with extenuating circumstances should be submitted with documentation for individual consideration. This documentation will be reviewed to determine if an additional benefit is payable according to the patient’s orthodontic benefit or if the patient should be responsible for additional charges. 13. How do you handle orthodontic pretreatments? Pre-treatment estimates are recommended for all orthodontic treatment. To request a pretreatment estimate, simply complete and submit an Attending Dentist’s Statement, making sure to provide all of the information needed for processing an orthodontic treatment plan. We will file these for your office with every patient who has an Ortho Consult/Ortho work up. 14. What should I verify when asking for eligibility?  Here at Dentistry Support, we verify all insurance for all aspects of dentistry.  Here is a snippet of the Ortho section of our customized Break down of Benefits form. This section is fully customized for your dental practice. For any additional questions, please feel free to email me directly at sarahbeth@dentistrysupport.com