OCTOBER 5, 2022 (29-MINUTE READ)

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Ben Tuinei:

Many doctors observe that their reimbursement agreements with insurance companies haven't changed for the last 5, 10, 15, 20, 30 years. Negotiating fees and how to negotiate fees or at least how to initiate it is probably one of the more important questions that are being asked by dentists these days.

Corey Brown:

I'm Corey Brown and this is Provide's The Path to Owning It Podcast, where I sit down with trusted industry experts in Provide's network to give you the tools and advice you need to take your practice ownership dreams into your own hands. From owning your own practice to expanding or improving an existing practice, we'll help pave the way for you to achieve your dental or veterinary career dreams and guide you through all the nuances of the practice ownership journey. Please make sure to follow us on Apple Podcasts, Spotify, or wherever else you listen.

Corey Brown:

On this week's show, we're discussing what you need to know when it comes to working with insurance carriers for your dental practice and how to negotiate fair and reasonable reimbursements. We are joined by Ben Tuinei, president of Veritas Dental Resources. Ben is an expert in professional dental insurance fee negotiations, and his company helps dentists achieve fair and sustainable reimbursement rates and employ proper billing and coding practices in an effort to maximize their practice revenue. Ben, thank you for coming on the show today. We're very happy to have you,.

Ben Tuinei:

Corey, it's my pleasure. And thank you for inviting me to be on your show. Looking forward to this.

Corey Brown:

Many dentists I've worked with over the years, insurance has always been something that is kind of baffling to most of them. So let's just start from the very beginning. How do insurance carriers generate what reimbursement rates look like?

Ben Tuinei:

That's an excellent question. I guess the short answer is they just make it up. They just go to the drawing board and they say, "Our loss ratios need to be X, which means this is the amount of money we're going to commit towards paying claims based on historical data." And then they come up with fees that will help them achieve a minimum amount of reimbursement to achieve a level of profit that is acceptable to their organization. But interestingly, about seven years ago, I was contacted by a firm out of Sarasota, Florida, and they were in the process of developing a plan design and a reimbursement fee schedule for a newer dental plan. They asked me to come up with a fee schedule. And I said, I was like, "You come into the wrong guy because I'm going to create a fee schedule that's good for the doctors."

Ben Tuinei:

And so I did, I created a fee schedule according to the FAIR Health data that was at the 60th percentile. And for most doctors in the community that I was sending the fees for, that was pretty much close to their office fees, maybe 10% less. And I thought that was a fair fee schedule. They didn't double check my recommendations against any other source. All they asked me was, "Do you think this is a fair fee schedule that will help us achieve a good result from a profit perspective?" In looking at the utilization data, I said, "Well, yeah, of course. It's a win-win for the dentist and it's a win-win for you guys."

Ben Tuinei:

But I was so surprised that I was given the authority to create the in-network fee schedule for in-network providers. I work for the dentist, right? My income is purely on the dentist side. Now putting my hat on and if I were strictly employed by the insurance plan, I would likely be thinking along the lines of every other insurance plan and creating fee schedules that everybody sees, that represent a 40 to 60% discount off of usual and customary. But to go back to your question how are reimbursements generated, the sophisticated answer is that, well, they're generated based upon what's going to give the insurance plan the best profit margin.

Corey Brown:

Gotcha. I don't even know if most dentists know that these fee schedules are negotiable. So how would they go about negotiating their reimbursement rates within insurance companies?

Ben Tuinei:

So this is actually a very hot topic in dentistry right now where inflation is at an all time high and many doctors observe that their reimbursement agreements with insurance companies haven't changed for the last 5, 10, 15, 20, 30 years. And so naturally, when you're trying to keep up with the wage wars that are growing on in inflation in the increased cost of supplies and goods and services, where most practices have a patient base that 90 plus percent of their patients are on insurance, so 90 plus percent of your income is controlled by an outside entity, negotiating fees and how to negotiate fees or at least how to initiate it is probably one of the more important questions that are being asked by dentists these days.

Ben Tuinei:

Well, the answer isn't so simple because as an individual doctor, you can call provider relations and request to negotiate your fees on that particular phone call, but you have to put yourself in the shoes of the insurance company. "If I were on their side, if my fiduciary responsibility was to prevent higher fees and prevent higher claims payouts, what do I need to do when I'm getting a call like that?" And the simple answer is that if you call in provided relations and say, "I want to negotiate fees," you're going to get roadblocked. Just like your front office team members when you have new labs and new vendors coming into your practice, that's how they respond, is they're going to keep you far, far away from the key decision makers.

Ben Tuinei:

So my recommendation to bypass the gatekeepers, if you will, is think about the most successful vendors that reach you, right? Cold calls where they reached you. And my version of this in dental when you're dealing with insurance is when I call provider relations, all I say is, "Hey, I have a question about a provision in my contract that I don't understand. Can you put me in touch with the network manager?" And that's it. I say, "Here's my phone number. Here's my email. Have them reach out to me." A lot of times the person on the other line will say, "Well, what's your question?" and I say, "Well, I don't have a whole lot of time. It's a little bit complicated. It's a question about something in the contract I just don't get. I don't understand it and it's going to take me a little bit of while to explain it. Love to set up a call with the provider relations manager or the network manager" and leave it at that.

Ben Tuinei:

If you say, "I want to negotiate," on their keyboard they're going to look for the F11 script, press that button and they're going to start reading, "Oh, we don't negotiate. Our fees are set by the market." And they'll just give you the same canned response and then they'll make a note under your file saying, "This doctor wants to negotiate. Ignore them when they call." You kind of have to sneak your way in, Corey, to get to the right people by just saying, "Hey, I have a question. Have them reach out to me." And then when you're in touch with that person, it's usually a network manager or a network recruiter title, those are people that will make decisions on what fee increases you're eligible for. That's how you started if you're doing this without any contact information from the insurance plan on who the network managers are.

Corey Brown:

And that's a fantastic tip. Thank you for sharing. Let's say that we do successfully somehow get past these gatekeepers, right? When it comes to actually starting to negotiate, do things like the size of your practice or the number of claims you're sending in matter?

Ben Tuinei:

Yes and no. I think history matters a lot to the insurance plans in terms of how long you've been credentialed. But at the end of the day, a lot of times when you try to come forth with what you feel is leverage, "I've been in network for 30 years. My dentistry is near perfected. I've been practicing it for a long time," or you come in and you say, "I have 300 dental practices," what we typically find is that a lot of times the larger DSOs do tend to get preferential treatment primarily because these DSOs may have acquired locations that already have great negotiated rates. So legally they can use that in their argument and say, "Well, we acquired a practice in Lakewood and their fees are 30% higher than the practice about a mile down the street. And we want to negotiate fair terms," right? So the DSOs have access to something that solar practitioners don't have, and that's data. Being able to know where the fee schedules are at with multiple locations and using the higher end fee schedules as leverage to negotiate for the lower end reimbursed practices.

Ben Tuinei:

In terms of size, that's what you'll find, is that the insurance companies would kind of test your knowledge on how much you understand about what the fairness clauses are in the antitrust laws when it comes to fees, even if you have a lot of practices. It's surprising that most groups don't know that. They don't know that you can leverage other locations to get fee increases for locations that are underpriced or undercompensated.

Corey Brown:

Well, now that we know how to properly negotiate with insurance carriers, I'm interested in hearing your tips and tricks for establishing proper billing and coding practices and what changes our listeners can make to elevate their practices revenue. We'll hear more from Ben right after the short break.

Corey Brown:

I'm Corey Brown and this is Provide's The Path to Owning It Podcast. We're back with Ben Tuinei, president of Veritas Dental Resources. Ben, I'd like to discuss ways our listeners can help maximize their revenue from within their own practices now. Do you have any recommendations for best practices when it comes to coding within one's dental practice?

Ben Tuinei:

Yeah, absolutely, Corey. I think it's important. And this goes without saying, I mean this is probably beating a dead horse, is really understanding the coding, right? I always start with, go to your practice management and pull a production by procedure report. Look at all the procedures that you build out to patients or to insurance and skim off the top 60 if you're a general dentist, right? Because that usually represents most of what you do, and really have a good understanding on those codes, what the code definition is.

Ben Tuinei:

A good example is when you look at the American Dental Association's coding book, and there are a lot of other coding books that non ADA people or entities sell that seem to be very helpful. But the American Dental Association, they own the CDT. And their definitions, that's the law when it comes to coding because insurance plans have agreed to follow that.

Ben Tuinei:

This is something that I'd say the majority of the dentists don't know. There's actually a leasing agreement that insurance companies have with the American Dental Association that require insurance plans if they're going to pay a claim that has CDT codes, it requires the insurance companies to honor the code definitions. So oftentimes when you understand the codes and you get a denial on a reimbursement, you could easily argue, "Well, you're changing the definition of this code," right? Classic example, crown and buildup. The CDT definition for a buildup, it is required when the tooth needs a foundation that the crown would retain to. The buildup is necessary to retain the crown, right? Otherwise without the buildup, you can't seat the crown. And a lot of insurance companies would deny the buildup saying, "Well, the buildup wasn't necessary, or the buildup is part of the crown reimbursement." And those are the two of the most popular things you see with the buildup.

Ben Tuinei:

Well, if it's denied because it wasn't necessary, that's because you didn't include in your narrative that the crown was necessary for a retention, or maybe you did and it was still denied. But that's what you have to use. You have to use the code definitions and even call out the insurance company saying, "Look, you've agreed not to change the definition and you're violating your agreement with the ADA by saying that the buildup wasn't necessary when in my clinical experience, and I'm the only one in this situation that's allowed to diagnose dentistry and determine whether the buildup was necessary or not, I have the license to determine that. And according to my license, the buildup was necessary and so therefore the benefit should be made payable because of that."

Ben Tuinei:

And what you'll find with the insurance companies and when you speak to them with that level of knowledge, a lot of them just pay up, right? And then they stop denying the buildups because they're like, "Well, this doctor knows his or her stuff." The part where the buildup is bundled, where the insurance says, "Well this is part of the crown reimbursement," that's a classic reimbursement policy, and this is a hidden policy that they don't ever disclose to you. They don't ever want you to know this. But when you contact them and look at their coding resource guys, or sometimes they call it policy and procedure manual, it clearly states in there that they will not reimburse a buildup unless the crown is reported on the seat date, right?

Ben Tuinei:

A lot of practices report the crown on the prep date and the buildup goes in with that. But the insurance plan will say, "Well, we're just not going to pay it separately unless the crown is reported on the seat date. You filed them on separate claims, on two different dates of service, the dates of service that you actually deliver the buildup, the prep, and the seat." So that's how you unbundle things. But you won't know about this unless you understand those policies from the insurance plan.

Ben Tuinei:

So two things here to kind of recap what my suggestions are, is number one, understanding the CDT coding for the sole purpose of enforcing the clause where the insurance plan cannot change the code definition. They do it all the time to deny claims. And then number two, understanding the insurance plan's own policies when it comes to how they reimburse claims. Because they're entitled to tell you, "Well, we want you to submit the claim this way on two different dates, on the actual data service that you perform them. Don't bundle them into one claim form." They'll let you know that in their policy and procedure manuals. So understanding those two things I think will give you a competitive edge in reducing the amount of denials and also getting paid for buildups because a lot of practices don't submit buildups anymore. For a practice with 2,000 patients, I mean that's 60 to $120,000 a year that you're just leaving on the table or throwing out the window, if you will.

Corey Brown:

For practices I used to work with, that was a very common thing that we would get back from insurance companies, is the denial of the buildup for some of those exact reasons until we learned a little bit more about proper coding and billing techniques. So kind of same question, but now onto billing. What other kind of tips can we give providers about billing or submitting these claims to insurance that would help them with their reimbursement?

Ben Tuinei:

Well, there's a number of things that I can at least speak to. One of the things that comes in mind that seem to be a critical part are non-covered services. I believe there are 33 states in the United States that have passed a non-covered service law, which basically says that especially if you're a network, a dental plan is prohibited from telling a dentist that they have to limit their fee or reduce their fee for a non-covered service. In other words, in those states, the doctor is 100% entitled to collect their full fee for non-covered service. Every state law defines non-covered services differently. So if you're not familiar with your state law or if you don't know if you're in a state that has such a law, all you have to do is Google dental non non-covered service legislation and you'll find a number of different websites that will outline which states have a non-covered service law. Almost all of those websites will have a link to taking you to your state law if you are in one of those states.

Ben Tuinei:

I would read through that because I often see doctors doing veneers as an example where they might charge $1,200 for veneers, but the insurance fee schedule says $600, right? And the doctors are like, "Well, no, I'm going to collect my full fee." So they do that, they submit the claim to an insurance plan. The insurance plan would come back, they'd say, "Well, this is not a covered benefit, so there's no reimbursement and the patient only owes 600." So they're giving the patient the expectation that "Yeah, you still get a discount," which is a false expectation.

Ben Tuinei:

Well, you know this Corey. When you look at the EOB on the right hand side where it has a section for different codes and you look at the code and you go down to the note for that code and those EOB say, "If this doctor's located in a state that has a non-covered service law, the patient would then be responsible for their full office fees," right? Many practices miss that, where they give the patient a refund.

Ben Tuinei:

I recommend looking at non-covered service laws and your ability to collect for non-covered services because I lost count of how many doctors that I talked to that don't do veneers anymore. They don't do night guards, mouth guards, they don't do a high level of cosmetic dentistry anymore simply because they can't afford to do it with the reimbursement structure. Now, the high end cosmetic stuff like your beautiful master ceramic anterior work, a lot of times those single unit crowns could cost 300, 400 up to 700 or more, right? And then the maximum allowance is 750 bucks. Of course, nobody's going to do it for an in-network fee.

Ben Tuinei:

So the option there is many doctors do upgrades, where you can add what I call an added value fee. Essentially where that added value fee comes into play is that you have the cosmetic needs for the patient, but you have insurance coverage that's limited to covering crowns for certain reasons. They don't cover crowns for cosmetic purposes. Or even if you do need a crown because of decay where the crown would be covered and you chose to get a number of cosmetic crowns, the insurance plans will cover basically the functionality of the crown, right? "Does it fit? Does it function? Seat it. Put it in and we'll just cover for the basics." They don't cover cosmetics and that's clearly written in the contract between the patient's employer and the insurance plan, or the patient directly and the insurance plan. In fact, all of those contracts, Cory, that I've been able to review, they all say that if the patient chooses an added value treatment that is above the scope of coverage for a covered procedure, the patient will be responsible for the additional fees associated with that treatment.

Ben Tuinei:

Unfortunately, we either give it away. In dentistry, we just don't do it because we don't know that these options to charge more exist. And then also when you submit a claim to an insurance plan and it comes back and you submit the 999s for all the cosmetic and it gets disallowed, right? Insurance plan says, "Nice try, Joe, but you can't collect that from the patient" where they're now violating the patient's for added value. Those things can be fought. But what I would recommend for those higher extensive cosmetic cases, if we can submit the crowns and get coverage under the policy terms, yes, we'll get some reimbursement there. But for the quote "upgrade" or the added value stuff, I use the high tech law as my protection as a doctor. High tech, you can look it up. Pass in 2009 I believe. But that allows patients to use insurance waivers to have a direct compensation relationship with the doctor for those procedures to where under no circumstance the doctor would ever be subject to an audit for that type of direct relationship.

Ben Tuinei:

So the upgrade or the added value components that you're charging the patient, the insurance governance is not included, right? The insurance can never get involved with those types of non-covered services or upgrades or added value that you're charging the patient. And the nice thing about doing that is that you don't ever run the risk of an insurance plan telling the patient they shouldn't be paying for those added value things.

Ben Tuinei:

Now that's a loaded concept, Cory, that I want to warn listeners that are hearing about this, is that you can't just tomorrow start doing that. There are laws to consider, there's informed consent requirements to consider, but we're just scratching the surface on answering Corey's question on what can you do from a billing and coding perspective to get more. And to me, when I talk to practices across the country, this is actually a big one, where practices either don't collect for those added values or they do the procedure at a loss.

Corey Brown:

Yeah. In your opinion, do you see value in providers outsourcing when it comes to billing these procedures? Or do you see them having more success with them keeping it in house and saving the cost of billing?

Ben Tuinei:

It depends on your current situation. Right now, a lot of practices are losing employees and they're having a hard time replacing those employees, mainly because these employees are flocking to businesses that allow them to work from home, right? Like billing companies as an example, they're not having a hard time finding employees because hygienists and dental assistants would rush to opportunities where they can make the same amount of money or more working from home. So many practices struggle with replacing insurance coordinators that have left. So yeah, outsourcing to companies that do this may be your only option or one of your best options in terms of keeping that accounts receivable activity continuing to go forward so that you don't have cash flow issues. I'm a big fan of outsourcing. We do it all the time. Most companies do this where you're pulling in experts from outside of your office to come fill a need. And I guess from a business perspective, that's the big question, is what needs do we have and can we find people outside of our practice from an affordable perspective.

Ben Tuinei:

I had breakfast this morning with a company out of California, and they even mentioned to me that they no longer hire in Southern California anymore simply because the pool of available candidates for the type of talent they're looking for is no longer available. So guess what they're doing? They're looking nationwide. They're trying to find talent wherever they can find it. And you might want to consider that too. If you don't want to outsource, cast the wide net. Not just your state. Look for talent all over the country. Especially when it comes to submitting claims, right? You can log in remotely. Somebody in your practice can scan those EOBs so that you know can share that with your biller. But be creative in terms of looking at all the opportunities that'll fit your circumstance in terms of where you're at with staffing needs.

Corey Brown:

And for those who do choose to keep this in-house, is there any sort of software that you can suggest that would help facilitate submitting claims?

Ben Tuinei:

Every practice management software out there has different function on how to batch claims and how to submit them, and a number of different clearing houses that will help you deliver those claims to the insurance companies. My recommendation there is you're going to be on a practice management software that a new hire may or may not understand. I think it's critical to have that person trained on using your software.

Ben Tuinei:

I was reading an article the other day where a consultant who've been in dentistry for 40 years, he said that we're only using 10% of the practice management softwares that are out there. We are unnecessarily giving ourselves a headache over insurance administration because we're not using all the tools that are available. I would recommend, no matter if it's Open Dental, Dentrix, Eaglesoft or Curve or any program that's out there, it's worth the money to get your team members trained. Just like you would go out and pay for CE, right? It is totally worth the money to invest in getting your team members CE on how to maximize the use of that practice management software. Especially if your accounts receivables is out of control, you need to make sure that you're getting all of that money from the insurance plans as well as from the patients on whatever copayments that are due. But we make too many mistakes with our own practice management systems and not using them efficiently.

Ben Tuinei:

Now, that's my first advice just on a general practice management perspective. If I may, you ask me a recommendation on a software, there's a software out there that I use to help perform somewhat of an insurance audit, and that one's called DentoMatrix. They don't actually help you submit your claims or process claims or anything like that, but they help you understand where your leaks are, right? "Where am I losing money?" Because either undercoding or lack of submission on certain claims or delay claims or insurance specific issues that your team members may not have caught.

Ben Tuinei:

Having a nice thorough insurance audit is very important. They call it a practice leaks report, basically what money's leaking from the practice, right? And I like that because when you perfect using your practice management program and you do these insurance audits with DentoMatrix, what you'll find is opportunities on where to refocus your training, right? "Okay. Here's where we need to look at training moving forward." And that helps you plug the holes in your ship. So in addition to what you're currently using, I recommend DentoMatrix. I don't know if you guys heard of them, but happy to share more. Probably the best solution for an insurance audit in the United States of America.

Corey Brown:

I think that's great advice. And then I'm sure a lot of our listeners would get many benefits out of doing that. As we close here, let me just ask you kind of one more thing. What's the single best thing a provider can do when it comes to billing and coding to get the most out of their reimbursement and maximize their revenue?

Ben Tuinei:

What comes to mind immediately is being an expert, having all the training necessary, the education, the current knowledge on CDT combined with what we talked about and understanding your practice management software. You want to make sure your accounts receivable is taken care of fast, right? That there's nothing out there that's pending. Getting that caught up in cleanup ASAP. And the only way to really achieve that efficiently is knowing what the shortcuts are in your practice management system, understanding the CDT codes and making sure you're not leaving anything off the table.

Ben Tuinei:

So to me it's a function of education, right? Treat your team members just like you would treat your own dental license as an asset in terms of making sure that there's constant continuing education. Now I get it, there are some really great courses out there that are very expensive. At least a positive aspect about the pandemic that I can least speak to when it comes to CE, a lot of CE is available now online. And what you'll find is that from a front office perspective, in this day and age, I've never seen the amount of front office online training videos.

Ben Tuinei:

Before 2020, most of these training videos never existed. But because we're headed in a direction in a virtual front office, if you will, where a lot of these functions are now being done in people's homes, check out the various different CE options for your front office team members. Some of them give you the ability to track where they're at and test their knowledge, but you'll quickly be able to know whether the CE is working with the efficiencies or lack of efficiencies that are occurring in your practice or these team members, right?

Ben Tuinei:

But at the end of the day, education is key. If everybody's educated with their specific role and has a plan for continuing education to keep current on the billing practices, what you'll find is you'll have a very, very solid group of team members that won't fail you. They'll be good at resolving those issues.

Ben Tuinei:

One last thing I want to add to that, if you don't mind, Corey. I'm all about quality. I speak about that. Every conference talk I give, I open up with quality, right? When you look at your team members from the perspective of quality, we focus a lot on the clinical quality, but when you look at the team members in this day and age, I think building them up to the level of quality that you would treat your clinical work would take you a long way. I've shifted and adjusted my way of thinking, and when we hire and when we train our people, it's like, "How do I get them to take that next level of responsibility in their practice?" I've adopted somewhat of a Fortune 500 level approach where they're getting CE every two to three months and they're being paid to go to that CE. And that's paid off for us significantly in terms of the value of our current people and the long-term retention of people that love learning and becoming better at their craft, short term and long term.

Ben Tuinei:

So if anybody wants some resources on some of the front office CE, not through us, but a lot of companies that we know that we've taken their courses that we love them, email me. I'm happy to send those resources to you if you find that might be a benefit.

Corey Brown:

Well, Ben, thank you for sharing your expertise with our listeners. If they would like to enlist your services to help with their own reimbursement rates or billing and coding suggestions, how can they reach you?

Ben Tuinei:

Feel free to visit our website. It's veritasdentalresources.com. Veritas is spelled with a V as in Victor, V-E-R-I-T-A-S, dentalresources.com. Or you can give us a call 888-808-4513. Or you can shoot me an email. My email is ben@veritasdentalresources.com.

Corey Brown:

Thank you so much, Ben. We really appreciate you taking the time to educate our listeners in ways they can negotiate their reimbursement rates from insurance carriers and simple changes they can make within their practice to maximize their profit. So thank you very much. I'm sure we'll be talking to you again soon.

Ben Tuinei:

It's been my pleasure. Thank you, Corey.

Corey Brown:

Thank you for joining us for this episode of the Path to Owning it. If you are ready to take your practice ownership dreams into your own hands, be sure to visit getprovide.com to pre-qualify and browse our practice marketplace or check out our news page for more helpful resources. The Path to Owning it is brought to you by the team at Provide with production assistance from Sarah Parkey, Cody Changet, and Liv Connaughton. And it's produced by Podcamp Media, branded podcast production for businesses, podcampmedia.com. Producer, Dusty Weis. Editor, Larry Kilgore III. For Provide, I'm Corey Brown. Thanks for being on the journey with us.

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