Mastering medical billing takes time and commitment, but the long-term benefits are worth it. Here’s how to speed your practice’s transition by creating smart workflows and outsourcing the hardest parts.

By Laurie Owens, CPB, CPC, COC

IN DENTISTRY, we’re used to immediate results. But medical billing plays by a different set of rules. The good news is that doctors who put in the time—and enlist the right outside help—ultimately enjoy significant long-term benefits. Here’s a rundown of what to expect so surprises won’t slow you down.

Expect a workflow shift, not just another billing task. Medical billing isn’t about replacing CDT codes with CPT or ICD-10 codes. Instead, it’s about recognizing which cases qualify as medical and properly documenting and submitting them to a specialized biller. Rather than relying solely on dental insurance, staff must learn to identify cases involving bone or soft tissue grafting, trauma, infections, musculoskeletal deficiencies or chronic oral pain. Initially, it’s normal for teams to miss opportunities simply because they are not accustomed to identifying medically necessary criteria.

Train your team—and designate a champion. A medical billing company can only submit claims based on the cases identified by the dental team. It’s not enough to outsource billing; the team must actively participate. The first hurdle to ROI is ensuring the office consistently sends complete cases for review. This involves acknowledging qualifying cases, collecting clinical notes and imaging, and submitting them promptly. Practices with designated staff liaisons who oversee this process see faster ROI. From flagging procedures to submitting all necessary documents, having a “medical billing champion” in the office boosts success.

Prepare to jump through a few hoops. Medical insurance companies often treat dental-originated claims with extra scrutiny, requiring detailed documentation and often delaying payments. Coverage varies widely between plans, with some requiring pre­authorizations that can take weeks. Medical carriers may also insist that dental plans be billed first, leading to delays. Documentation must clearly show functional impairments or claims risk being denied. As such, your first few months will likely involve learning how to navigate payer rules and overcome initial denials.

In time, confidence grows and reimbursement becomes much more consistent.

Create a reasonable timeline for your goals. ROI depends on submitting enough cases. Realistically, it takes one to three months for staff to become accustomed to identifying cases and providing complete documentation. By months four through six, regular claim submissions should begin, but preauthorizations can slow payments. Around months seven through nine, most teams have improved: Confidence grows, denials decrease and
reimbursement becomes consistent. (Submitting cases weekly and tracking metrics like denial rates and reimbursement timelines also helps.) Finally, by months ten to 12, your systems should be optimized, and ROI will become measurable.

Outsource the most frustrating parts. Working with a qualified outside medical biller will let your team focus on treatment. Expert medical coders will scrub your claims prior to submission, follow up to ensure correct processing, appeal on your behalf at the first level and provide monthly itemization of claims completed and the fees associated with recurring charges.

Medical billing for dentistry might not be a quick win, but just like any winning game plan, success comes from consistent effort and teamwork. Every time your staff flags a medically necessary procedure and submits it to the biller, you’re taking another step closer to unlocking a steady revenue stream that creates long-
term financial stability and better patient access to care.

LAURIE OWENS, CPC, CPB, COC is the director of medical billing for PPO Profits, one of the market’s leading providers of dental fee negotiations. She has more than 20 years of experience educating dental practices on billing medical insurance and increasing practice revenue. PPO Profits is part of Benco Dental, the publisher of this magazine. Contact Owens at laurieo@ppoprofits.com.