Assessing Your Dental Benefits Systems for the Future

Many providers want to review their claims management procedures yet lack the time to properly devote to the task. Also, it's rare to have an uninterrupted opportunity to generate and evaluate reports. Dentists can make the most of this time when their practices are focused on emergency and urgent procedures. Now is an ideal time to implement a proactive system rather than a reactive one.

As a part of your revenue cycle, managing dental benefits is paramount to ensure cash flow during lean times. This particular job function is very rarely implemented before it is necessary, yet it will have an incredible impact on your practice success.

Changing business environments require flexibility in your systems. In uncertain times it's easy to be driven by emotion, but it's important to think strategically, not emotionally. I'd rather you have enough information to make impactful decisions, even under pressure.

It's standard practice to train the dental benefits coordinator with a historical and ad hoc slant. Allow me to explain. Currently dental benefits coordinators are required to perform the following duties:

  • Obtain eligibility and benefit information for upcoming appointments.
  • File claims daily.
  • Ensure all claims have the proper documentation.
  • Check electronic claims submissions reports daily.
  • Run the dental benefits aging report and follow up on claims.
  • Post checks as they arrive electronically or by mail.
  • Appeal any claims.

What stands out about all these tasks is that they are based on current and past benefits activity. They were created because another task expanded. Claims management itself is a huge job that requires oversight by managers or owners. While all these tasks are important, they are not necessarily helpful when planning for your dental benefits system strategy. They are simply tasks. Let's identify what is going well and what is not. From there we can look at the overall system with the intent to improve the factors that need to be fixed.

What is it about your system that is not working? Most often I hear that it is gathering benefit information and appropriate documentation to submit claims. After that, the process of formulating an appeal is another stumbling block for most dental benefits coordinators. I find that this is due to a lack of clinical knowledge. A new-to-dentistry employee will not know how to compose an appeal for the doctor to review. This new employee won't see that clinical notes could be improved so that information isn't repeatedly requested.

Let's discuss gathering the breakdown of patients' benefits prior to the appointment. You'll achieve this best by relying on your electronic systems to return this information to you. An alternative is to use a third-party outsourcing company to gather eligibility and benefits. Consider letting this third-party outsourcing company and/or your software do the heavy lifting, so the dental benefits coordinator only has to fill in the gaps.

Why am I so insistent on strengthening this part of your process? Patients expect — and should have — accurate cost estimations. Even with dental benefits, our patients often must save for or finance the cost of their care. If we are not accurate, it erodes the patient's trust in our services. An unexpected bill is never a pleasant surprise.

Documentation continues to challenge most teams. If the office does not use templates, then there is always a chance that key information will not be recorded. If you are utilizing templates, then it's a good idea for the clinical and administrative team to review these yearly. Many dental benefits change, and if there is a simple tweak that can improve claim processing then you'll be able to change it quickly. An example of this is changing your template to include “age of existing restoration.” This will prompt the assistant or dentist to ask the patient while they are in the chair rather than your dental benefits coordinator tracking down the patient to ask them over the phone. Improving your documentation skills will improve your reimbursement. Many claims are unpaid due to insufficient supporting documentation. You can avoid this by revisiting and improving this system.

From a strategic point of view, commit to making — and recording — the following observations:

  • Which carriers cause you the most work?
  • Which carrier seems to give you the most inaccurate information?
  • Is there a carrier whose fee schedule doesn't adequately reimburse you after expenses and labor?

You'll want to share this information between the administrative team and the doctor. Many doctors are unaware of the extra cost of participation which is labor and excessive paperwork. The first step is to notice and document these observations so that you can make fact-based strategic participation decisions. If you decide you must take action with a carrier then you can – as a team – decide how you will approach affected patients with your decision. Your whole team will need to be on board with any dental benefits participation decision you make. They will most likely talk with the patients about benefits more than you will.

By knowing your dental benefits system's strengths and weaknesses you'll be better prepared to make smart, quick determinations. Ideally, you'd track these observations for at least six months before you make any new decisions.

Do you have questions about working with patients' dental insurance plans? Visit the ADA's FAQs on dental insurance claims.

About the author

Ms. Duncan is a speaker and podcaster who focuses on dental benefits and management issues. She is the author of Moving Your Patients to Yes: Easy Insurance Conversations and has contributed to several ADA publications. She can be reached via her website at