Belle DuCharme

CDPMA, Dental Training Consultant

Insurance Specialist Necessary for Practice Cash Flow

Adequate business staffing has always been a dilemma in many dental practices.  Do we have too many or not enough staff? Everyone is busy, and still, many tasks don’t get completed.  Maybe the practice can’t afford to hire more than one experienced Business Coordinator (Office Manager) to do it all. If the practice is seeing under 22 patients a day, and 70% of the patients have PPO dental insurance, one talented Business Coordinator can do the work with diligence.  However, there will be areas that need attention, such as calling unscheduled patients, marketing, keeping up with social media, and collections.

 Insurance filing and follow-up are a traditional part of a Business Coordinator’s job description.  Cash flow can be seriously interrupted if the person in charge is overwhelmed by unpaid claims that need written appeals and follow-up calls to the insurance companies.   Insurance in 2020 will be increasingly complex and require far more attention than ever before to keep the money flowing into the practice bank account. 

 If the practice is seeing more than 22 patients a day with 85-90% of the insured, then it is wise to have a second full-time person who concentrates on getting claims filed and paid promptly.  More insurance policies require the medical policy of the patient billed first, and many dental services will be covered by the medical policy and not by the dental policy.  It is vitally important to hire an insurance coordinator who can bill dental and medical claims.

To facilitate hiring the qualified, I have provided an Insurance Specialist Job Description:

Insurance Specialist Job Description:

  1. Monitors and resolves unpaid claims on the Accounts Receivable report/Outstanding Insurance Claim report (goal is zero (0) dollars in unpaid claims aging to 90 days
  2. Monitors and resolves secondary insurance claims to be zero (0) dollars in 90 days aging.
  3. Verifies personal and insurance information on each patient and guarantor’s account for accuracy before filing the insurance claims.  Including but not limited to name, DOB, address, gender, relationship to the subscriber, subscriber ID, group number, employer, billing address for the insurance company.
  4. The insurance specialist submits each claim to the correct clearinghouse via electronic submittal or paper submittal to the insurance company on the most current claim form.
  5. Follow up via phone or online any claim that is rejected or denied, correcting any mistakes and following the claim denial process of each insurance company to ensure the claim is paid.
  6. Verifies patient’s eligibility, benefits, and coverage via online, phone, or from patients insurance processing manual.  Also, checks for frequency limitations and history on specific treatment such as SCRP and crowns and policy limitations such as “missing tooth clause” or “wait period.”
  7. If the policy is an in-network PPO, the insurance specialist enters the current fee schedule to be able to produce a more accurate treatment plan and financial agreement with the patient or guarantor.
  8. Keeps up with yearly changes to the CDT (Current Dental Terminology) codes and has a good understanding of the codes and their proper application to the treatment proposed and rendered. Advising the clinical team if the code is chosen is not the best choice for the treatment provided.  Always code what you do and have the clinical notes to back it up.
  9. Keeps communication with the clinical staff on the positive to be able to attain clinical records necessary to substantiate the claim and get it paid.  Must be a team player who has a positive communication style.
  10. Has experience in looking up ICD 10 diagnostic codes and CPT codes to be able to bill treatment to medical insurance, in addition to practical knowledge of billing dental/medical services to medical insurance policies.
  11. Is able to post insurance payments correctly to each patient account and to do the necessary adjustments per each contract.  Sends statements if the balance due. 
  12. Must be able to positively communicate insurance coverage to each covered patient or guarantor and set up a financial arrangement that the patient or guarantor understands and agrees to by signature.
  13. Must be able to create a short narrative from the doctor’s clinical notes for services requiring descriptions.
  14. Must be able to attach identifiable documents such as periodontal charting, clinical records, radiographs, and intra-oral photos to the claim before submittal to the insurance company.
  15. Monitors claim submission reports and outstanding insurance claim reports and addresses errors or delays immediately.  Reports to the Office Manager or Dentist.
  16. Serve as back-up to the Business Coordinator or Office Manager to answer phones and check in or check out patients at the desk.

As you can see, the position of Insurance Specialist is critical to the success of the practice and to ensure healthy cash flow.

Finding an employee who can deliver all these skills may be very challenging.  Consider outsourcing to a company that hires only the most experienced and skilled in the arena of insurance billing.  Reach out to eAssist and let their insurance specialists improve your cash flow starting today.

Dental Billing Tips and News for Pros; Edition #147


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