Episode 81: Are you a Backyard Biller or a Billing Expert?

03/10/25 • 32 min

Dental billing has undergone a dramatic transformation since the carefree days of the late 1990s. What was once a straightforward process—send a claim, get paid, move on—has evolved into a complex system demanding meticulous attention to detail and strict compliance measures. The reason? Insurance companies have woken up to the staggering $12.5 billion lost annually to dental fraud, and they're scrutinizing claims like never before.
You don't need to be committing actual fraud to get caught in this web. Cutting corners, skipping steps, and clinging to outdated "backyard billing" habits can quickly put a target on your practice. Are you submitting claims without checking clinical notes? Skipping attachments to get claims out faster? Using coding loopholes that worked a decade ago? These practices aren't just inefficient—they're potentially putting your practice at risk for denials, audits, and recoupment demands.
True billing expertise isn't defined by years of experience but by commitment to compliance and continuous education. It means verifying clinical documentation matches what you're billing, understanding dental necessity requirements, staying current with coding changes, and implementing robust follow-up systems. It means knowing when to push back when insurance companies request additional information despite receiving sufficient evidence the first time. Most importantly, it means understanding your state's prompt pay laws and holding insurance companies accountable when they attempt to delay payment beyond legal timeframes.
The transition from backyard billing to compliant billing isn't complicated, but it requires intentionality. Start by implementing daily report monitoring, creating standardized billing protocols, and ensuring your team understands compliance requirements. The reward? Fewer denials, faster reimbursements, and significantly less stress from chasing payments that should have been received the first time. Remember: the goal isn't just getting claims paid—it's getting them done right.

Want to learn Dental Coding and Billing? Join here:
https://tr.ee/efzYrY7mp-
Would you like to set-up a billing consultation with Ericka? She would love the opportunity to discuss your billing questions and see how Fortune Billing Solutions may help you.
Email Ericka:
[email protected]
Schedule a call with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Perio performance formula:
(D4341+D4342+D4346+D4355+D4910)/(D4341+D4342+D4346+D4355+D4910+D1110)

Got questions? Send Ericka a Text!

https://calendly.com/ericka-dentalbillingdoneright/30min

Perio performance formula:
(D4341+D4342+D4346+D4355+D4910)/(D4341+D4342+D4346+D4355+D4910+D1110)

Previous Episode

Episode 80: A HIPAA-Centric Approach to Dental Billing

Got questions? Send Ericka a Text!

Uncover the critical connections between HIPAA compliance and dental billing practices in our episode featuring host Ericka Aguilar. Discover how safeguarding patient privacy extends beyond ethical boundaries to play a pivotal role in averting billing fraud in dental practices. We delve into the cutting-edge strategies employed by insurance companies, such as predictive analytics, to detect inconsistencies and initiate audits without relying on whistleblowers. Erika sheds light on the risks associated with common pitfalls like inappropriate code adjustments and the negligent waiving of co-payments that insurers might interpret as fraudulent activity. By gaining a deeper understanding of insurance audits and adhering strictly to HIPAA's privacy, breach, and anti-kickback policies, dental professionals can uphold their practice's integrity and maintain the trust of insurance companies.
Explore the heightened scrutiny dental offices face due to the rise of AI in insurance auditing, as Ericka highlights the dire consequences of billing inaccuracies, including high denial rates and the ominous threat of clawbacks. With the potential for significant financial repercussions, she emphasizes the importance of accurate billing and the dangers of fraudulent resubmissions. Learn how diligent denial tracking and effective appeals can be your defense against unnecessary audits and penalties. Hear practical advice on how to navigate the complexities of maintaining compliance, including when to involve the insurance commissioner to protect your practice from potential pitfalls and maintain ethical billing standards.

https://calendly.com/ericka-dentalbillingdoneright/30min

Perio performance formula:
(D4341+D4342+D4346+D4355+D4910)/(D4341+D4342+D4346+D4355+D4910+D1110)

Next Episode

Episode 82: Outsmarting AI: The New Dental Claims Game

Got questions? Send Ericka a Text!

Artificial intelligence has quietly revolutionized how dental insurance claims are processed, and most dental offices don't even realize it. Today we pull back the curtain on Novo Dynamics and their Novo Health Dental AI system that's scrutinizing your x-rays, documentation, and billing patterns before a human reviewer ever sees your claim.
The game has changed dramatically. Insurance companies have trained AI systems to review claims using very specific criteria determined by their own dental consultants—not treating clinicians. These systems don't just look at individual claims but cross-check x-rays across multiple insurance carriers, analyze your practice's billing patterns, and compare you to other providers in your area. If your practice performs more crowns, SRPs, or implants than what AI considers "average," all your claims face increased scrutiny regardless of their legitimacy.
This technological shift demands we evolve from merely submitting "clean claims" to creating "AI-proof claims." High-quality, clear x-rays that perfectly demonstrate necessity, concise standardized narratives, and meticulous documentation are no longer optional—they're essential. When AI improperly denies claims, request human review promptly. Document patterns of improper denials and report systematic issues to your insurance commissioner. The days of assuming a person will review your claim are over, but by understanding how these systems work, you can adapt your strategies to overcome these new barriers to reimbursement.
Ready to level up your billing skills and connect with fellow dental billers? Join us for our upcoming live workshop in Dallas! Send "Dallas" in a direct message to @dental_billing_coach on Instagram for your chance to win an all-expenses-paid trip to the event. Looking forward to diving deeper into AI and dental billing in our next episode where we'll share real-world denial stories and more strategies to beat the algorithms at their own game.

https://calendly.com/ericka-dentalbillingdoneright/30min

Perio performance formula:
(D4341+D4342+D4346+D4355+D4910)/(D4341+D4342+D4346+D4355+D4910+D1110)