We all remember the Aesop Fable, the Tortoise and the Hare. The hare (dental insurance) ridiculed the tortoise (medical insurance) for being too slow, and then challenged the tortoise to a race. 

In the beginning, the overconfident hare ran around in circles, mocking the tortoise before taking off. Midway through the race the hare thinks, “I am better, faster, and will always win against that tortoise.”  Because of that, the hare decides to take a nap!  

As the hare awakens, and starts on the track to finish the race, the tortoise has already crossed the finish line.  

During the race, the tortoise was focused on the prize…finishing.  Even though the tortoise is slow, he would continue even if the hare had already beaten him.  His goal was to cross the finish line. In the end, we are reminded that carelessness and arrogance never win.  

Now that we have taken you back to elementary school, think about how this applies to medical billing for dentistry.

Implementing medical billing is not something that can be completed quickly. Accuracy and careful planning are key elements in obtaining reimbursement. 

There is an order to implementing medical billing, like the tortoise, staying the course and keeping an eye on the finish line while overcoming obstacles along the way is imperative. 

With that in mind, let’s look at the best path to creating medical billing success. 

Step 1: Credentialing:

Note: This is not contracting as an in-network provider. 

Credentialing shows the medical insurance plan that the provider has an NPI I, NPI II, license, DEA, and malpractice insurance.  

Some other types of information medical insurance may require:

1. CAQH registration number: 

Call CAQH to ensure your file is open to medical insurance if you haven’t already completed this step.

2. Registration form:

Complete any registration forms required by the insurance company if they do not utilize CAQH. 

3. W9 form:

Smaller insurance companies may only want a W9 submitted with the claim. 

Getting credentialing right from the beginning will be a huge benefit. If you aren’t sure how to tackle credentialing, Devdent can help!”

Step 2:  Verification of Benefits (VOB): 

Verification of benefits, also known as VOB, is verifying that your procedure code is part of the plan’s benefits and is completed over the phone.

Note: This is completed over the phone because online portals provide very basic information and will not give you a clear picture of what the plan’s benefits are. This is because it is specific to the procedures you want to complete.  

Here is the information we get when your Imagn biller calls insurance:

1. Name of representative.
2. In-network and out-of-network deductibles and how much has been met.
3. Calendar year plan or plan year.
4. What percentage is paid for in-network and what is paid for out-of-network.
5. Code specific information and if this code applies to the deductible.
6. Is preauthorization required? Code by code.
7. Can we request a gap exception? Some insurance companies will require the patient to start a gap request.
8. Call reference number that verifies the content of the conversation.

Step 3: Preauthorization (if required):

If preauthorization is not required, insurance will not process a request. As an example, Medicare never requires preauthorization.  

Preauthorization will help you find out if procedure and diagnosis code are approved as plan benefits. 

Medical insurance will not give you any specific dollar amounts, however, you can figure out an estimated portion by following the process below. 

To get an estimate, you will need the diagnosis code story and medical records (chart notes). It is important to remember that if your records do not reflect the appropriate diagnosis codes, you cannot bill it. 

Medical billing is meant to get your patient’s portion to zero so that they pay nothing out of pocket. The goal is to utilize the medical benefits to reduce out of pocket costs and limit the amount of practice write-offs. When it comes to expectations versus reality, the more information you submit, the more medical insurance sees your consistency. 

As you begin a claim, verification of benefits, or preauthorization in Imagn Billing, there is a “save to draft” feature so if you get interrupted it will take you back to where you left off. 

Coaching clients can ask for our help! If you need us to double-check your work, we can then hop in, read your notes, and make sure your story makes sense before you send it for review. 

Don’t be a hare!  Remember, slow and steady wins the race to medical billing for dentistry!