📍 Hey friends. Welcome back to No Silver Spoons. I'm your host, Sarah Beth Herman, and this episode is part two of our insurance education series. In the last episode, we talked about CDT 2025 updates, claim follow-up rhythms, zero fee, claim issues, and umbrella plans. If you haven't yet listened to that episode, I would recommend pausing this episode heading back to the previous episode and listening to that one fully. That episode is the foundation today we're building on that foundation. We are going to explore the parts of insurance that nobody tells you, but that your practice absolutely needs to know, and maybe some of these things are little tidbits that you kind of knew.

Maybe you already knew them, but I promise you're gonna leave this episode. Feeling empowered in new ways, thinking about things just a little bit differently. One time I was talking with a friend of mine who said that her husband went with her on a retreat where they were learning all of these new things for their practice.

And she said to me that her husband left that event saying, hey, I already knew all of that. wanna tell you this. If you aren't actually taking what you're learning on this very podcast episode and putting it into action, it doesn't matter if you've heard it before.

So if you're hearing something familiar in this episode, take a note of it, write it down, and think, how can I put this into play if I haven't already been putting into play? And maybe that's the one thing you take from this episode.

The conversations that we're gonna talk about today are the ones that reps don't have with you. I'm gonna talk about some frying print that most people skip over. I'm gonna talk about some game changing tips that will help your office get paid faster and cleaner.

So whether you're an office manager, a treatment coordinator, a practice owner, or someone who's supporting a dental practice, virtually, this is an episode for you. So let's get right into it. Let's start here. Just because a rep says a procedure is covered doesn't mean it's going to be paid in full. Now maybe you're thinking, what are you talking about, Sarah Beth, well listen up for a second.

Let's talk frequency limitations. S We had a new client enroll in support for our offices and we had a new client who enrolled in dentistry support. We offer billing, eligibility, phone support, credentialing, medical billing for dental, you name it. They enrolled in our dental billing support and part of that support includes us working all of their outstanding AR at no charge.

We literally do not charge to work any old ar. Because we know that we are gonna get everything under control in their zero to 30 days, and our focus is on the current money. We are going to clean up all of their AR by a certain deadline and make sure that it's in clean and everything's orderly. But we don't charge to work the old ar, but we're wanting to uncover bad habits.

We wanna uncover patterns that we see. So, this office, they enrolled, and they kept getting fluoride claims denied for patients under 19. When we looked at how they verified benefits, we learned that they kept getting their fluoride claims denied because they were verifying that fluoride was covered, but they didn't ask how often.

Now that seems simple enough, but it turns out several of these plans only allowed fluoride once per calendar year, and the practice had been providing it every six months. Data from MetLife and Aetna's Provider guide shows that 40% of denials for preventive codes are due to frequency misinterpretation.

So many plans cover cleanings two per year, but others enforce once every six months. That difference could mean denial if your patient comes in too early. As for downgrades, most PPO plans still default to amalgam coverage for posterior composites. So if your billing doesn't include the phrase alternate benefit, applied, and a supporting narrative, that claim might be reduced or denied without explanation.

So some of the common downgrade denials are D 2391 through D 2394, your posterior composites. Those are what are downgraded to amalgam without prior notice. Now, D 27 40 is another one that can be downgraded to full metal coverage. If you're new to dental billing, write these down. Take notes on this. What your more traditional billers might not know is that some plans only downgrade if the tooth is not visible in the smile line.

So, make sure that you attach those intraoral photos so that you can prove what needs to be covered. Others might require documentation of allergy or patient preference for composite versus amalgam to override the downgrade. So, if you're a traditional older biller, you gotta write these down. I'm not trying to be facetious, but these are key things that you can add to your narratives that could help you get paid.

So, a couple takeaways here. Always ask your rep, what are the frequency limitations for this code? Are any procedures downgraded in this plan? Do any procedures require pre-authorization or documentation Attachments. Is there an alternate benefit language that's required on this claim? Now you might be thinking Sarah Beth, I know all of that.

I do all of that. I've been doing this for a long time. That's okay. I know that you know that, but I bet you you're still getting denied claims and you don't need to. We can move past that. You don't have to live in claim denials anymore. If there's anything I want you to know, it's to always document what the rep tells you.

Don't trust memory. Trust process. I'm gonna say that again. Don't trust memory. Trust process. Screenshot it. Record it. Upload it to the patient's chart. Do whatever you can to document how you knew this would be covered. If you want more training on this aspect of dental billing, you can visit our sister company Dentistry Support Academy, where we teach these front office skills in a way that sticks.

We also offer 90-minute virtual sessions at Dentistry Support where we answer your specific questions in real time. And very soon, we are going to be hosting live in a MA webinar where you can bring your toughest scenarios and get the support that you need. All of this is linked in the show notes.

Let's talk about coordination of benefits. I believe this is the silent killer of payments. Coordination of benefits is one of the most misunderstood and improperly managed aspects of dental billing, yet it remains one of the top three reasons claims get denied or delayed. According to Delta Dental and United Healthcare provider bulletins, I.

Coordination of benefits we talked about in our previous episode, but it does refer to how insurance companies determine which plan pays first when a patient has more than one active dental policy. While it sounds simple, it's layered in rules and exceptions that can tie your team in knots if it's not handled the right way.

So, I wanna talk about common coordination of benefit issues that delay or denied claims. So, let's talk for a moment about common coordination of benefit issues that delay or deny claims. One is submitting to secondary without attaching the primary EOB. Now, maybe you're thinking, I do this, I'm good at it.

My system does it for me. I still want you to know that it's required. So if you aren't someone sending that primary EOB, make sure you're sending it. Two incorrectly determining the order of benefits based on outdated birthday rule assumptions. Now, if you've been in dentistry for any length of time, it's kind of like these unspoken rules that we've just always adhered to.

It kind of goes back to the monkey story. If you don't know what that is, go to YouTube. Look it up. I'll link it in the show notes. It's kind of a funny little story, but. If you think about all the things, you've ever learned in a job before, sometimes you just do things cause everybody else did it. So, if you are receiving denials for coordination of benefit issues, see why?

See what's happening. Are you incorrectly determining the order of benefits because you believed in the birthday rule assumption? Go back to the drawing board, reach out to the reps, determine coordination of benefit properly. The third one is missing carve out language in one of the plans. And the fourth one is parents having coverage on a child but failing to identify custodial parent rules and divorce agreements that is so big in our pediatric practices.

I see it all the time. Here's what you need to know, the birthday rule, the plan of the parent whose birthday month or day falls earlier in the year is typically the primary for dependence. But this doesn't always mean that that's the truth for the exact plan you're looking at. This is what we've known historically, but that doesn't always apply in every single plan.

Check the notes, ask the rep. Make sure you know before you file that claim. Two, the carve out clauses. Some plans reduce payment to the amount they would've paid if they were primary, even when they're secondary. This is not standard coordination of benefits, but please make sure you know if there is a carve out clause and then the non-duplication of benefits. If you've never heard of this before, it basically means that there is a clause in the plan that prevents the secondary from paying if the primary already covered the full allowed amount.

You might say, hey, whenever I submit primary, I always get full payment from both, and then the patient ends up paying double for their services. That's not always the case cause insurances have caught on to this, so make sure there's not a non-duplication of benefits. And then the custodial parent rule.

If the parents are divorced, the custodial parent's plan is primary, unless court documents state otherwise. So, if there is a situation in play, you need to make sure you get all the information. If you catch wind that there are two plans because of a divorce. You need to be asking if there is a custodial parent rule that has dictated insurance policies.

Make note of it. If you're a pediatric practice, this is so important for you and if you're a general or any other specialty as well, but we see it most often in our pedo practices. A couple pro tips for you. Always request coordination of benefit policies from both carriers for dual covered patients.

Train your billing team to always scan and attach primary EOBs to secondary claims. Use color coded claim logs or tracking systems to manage dual covered patients and communicate with patients early. Ask if they have secondary insurance and what the coordination rules are. Make sure you are on top of it.

If you ask these questions upfront, you won't have dirty or messy claims In the end, coordination of benefit problems aren't just frustrating. They are costly to practices, but they're also completely preventable when you set up the right systems.

Let's talk about bottlenecks for a minute. So, what is really causing claim bottlenecks in dental offices? One of the biggest struggles we hear from dental teams, especially new clients, is that their claims have just been sitting there. So, what we learned is that the issue is rarely just one mistake.

It's usually a pattern of small errors that go unchecked. So, like I said earlier in this episode, we are always watching for patterns or habits that have continued on at a practice so that we can easily attack any outdated AR or old claims that are just sitting there. So here are our top causes of claim bottlenecks.

Missing clinical attachments, so your x-rays, Perio charting narratives using the wrong CDT code revision year, submitting with outdated insurance information, not attaching provider credentials like the NPI or the license number when it's required, and not following up with payers at consistent intervals.

So, we believe in following up with payers every 10 days as a minimum. And so, this sets us up for success because we can make sure that we are checking on claims and we're getting the results of that claim as early as possible to get it paid as soon as possible. I. According to Delta Dental's 2025 claims review guide, over 35% of dental claims are denied due to missing or incorrect attachments.

And here's what's more important, having trusted people in place who know what to look for, your billers are not just pushing buttons, they're. Analysts. They're investigators, they're patient advocates. When we support a dental practice at dentistry support, we train our team to look three steps ahead because we know what a small, unchecked claim error can snowball into.

So, what you can do is to have a claim checklist that includes x-rays, narratives, charting current CDT codes, EOBs, if they're secondary. Assign one team member to review the scent but not process claims every week. That way, you know, you've checked all your boxes. Educate the clinical team to note key language in their charting that supports claim narratives and regularly review your rejections and categorize by issue to see where patterns are forming.

We wanna help work through your office's bottlenecks, but you've gotta be willing to take the first step. We do offer strategy sessions designed to walk through your office cleanup and reorganization, plus custom training at Dentistry Support Academy. Don't just patch the issues, fix the problems. More details are in the show notes, so check there.

Our final section in today's episode is all about understanding non-covered services and fee capping. This is a policy issue that most practices overlook. Some insurance plans try to limit what you can charge a patient, even for procedures that they don't cover.

But in many states, legislation is changing. The Dental and Optometrist Care Access Act is pushing back against insurance plans, dictating fees for non-covered services if passed nationwide. This would allow providers to charge their full fee when insurance isn't contributing. No more forced discounts.

Your takeaway. Know your state's stance on non-covered service clauses. Review your PPO contracts to understand fee limitations and educate your patients early about what insurances won't cover. If you wanna learn more on how to train your team to talk confidently about fees and benefits dentistry Support Academy offers entire tracks on financial conversations and patient benefit education.

Let's bring this all home. Let's go to your, that's good moment of this episode. A few things to note if you haven't already been taking notes today. Just because a procedure is covered doesn't mean it's payable without limits. coordination of benefits. Mistakes are avoidable with a solid system.

Having the right people in place and giving them the right training saves time and prevents errors. It's an investment in your practice. Know your rights when it comes to non-covered services. You don't need to be an insurance expert overnight, but you do need to start asking better questions and building smarter systems.

And remember, if this feels overwhelming, you're not alone. Every dental practice in the United States deals with it. If your office can use some help, I've mentioned several resources throughout this episode, but I also personally mentor and coach teams. Through all of this, let's schedule a call and map out your biggest insurance struggles and create a better plan.

All of my links are in the show notes, including how to Work with Me, my digital trainings, and done for you insurance support. Thank you for being here, and I'll catch you on the next episode of 📍 No Silver Spoons.