Trends in Insurance Reimbursement with Dr. Roy Shelburne


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Trends in Insurance Reimbursement

Episode #432 with Dr. Roy Shelburne

Everything you know about dental insurance today — well, it may be different tomorrow! So, to help you stay ahead of the trends and changes and protect your practice, Kirk Behrendt brings back Dr. Roy Shelburne to share his expert advice. There are ways you can maximize your reimbursement, and it starts with one thing: read and understand your contracts! If you want to collect every cent you're entitled to, listen to Episode 432 of The Best Practices Show!

Main Takeaways:

Dental insurance rules are constantly changing.

Always read and understand your contracts.

Double and triple-check your documentation.

Audits are done for a reason, not at random.

Be prepared when communicating with insurance.


“What you know about dental insurance today, the rules are going to change tomorrow. The codes are going to change tomorrow. So, we have to continually keep our focus on understanding and doing it correctly.” (4:36—4:52)

“[Insurance companies] like claims that are clean. They don't like to have to send it back and ask for other information. It’s harder for them and it’s more expensive for them. So, that's the reason why they're concerned about having it done the right way.” (8:29—8:42)

“So many dentists look at the contract and only review the fee schedule and think, ‘Okay, I can live with this fee schedule.’ But, in fact, there are all kinds of other limitations or restrictions on that plan that have a broader effect on the reimbursement scheme. So, they aren't aware. It’s like, ‘Well, this says it’s going to pay at this amount.’ However, there's also a different section in that contract that says, ‘Oh, and by the way, under this situation, we can't pay. Under this situation, we can't pay.’ So, it’s understanding, first off, the restrictions and limitations not only in the fee schedule, but also the way the contract is set up.” (9:18—9:59)

“The contract, primarily, is seldom read. Or if it’s read, it’s misunderstood. And secondarily, the contract that you've signed with the insurance company gives them the right to change that contract with 30 days’ notice. So, not only have dentists not read the contract when they signed on originally, those letters that the insurance companies send to their network dentists periodically could have some very significant modifications to that contract where they're letting you know it’s changing, and the person who gets that letter, or the doctor who gets that letter, looks at it and goes, ‘This is junk mail,’ dumps it in the trash can, when the contract has been changed and it’s been disclosed in that letter that you haven't read.” (10:14—10:56)

“The concern is, we’re talking about inflation and how it is now increasing at a not foreseen rate. Maybe, what was it, in the ‘80s, it was similar to this? But now, do the costs for dentists go down? Absolutely not, as far as you have to pay teams more money. We have to be competitive in the employment market today. And as far as the supplies, they’ve gone out the roof. And what has been the trend with reimbursement? Has it increased? No. Absolutely, it’s going down. How do you make that work? How do you work harder and make less? And how many additional patients do you have to see, and what's your capacity?” (13:39—14:33)

“As far as the EOB, I think it’s meant to be obtuse, to be able to not follow. The more confused you are, the less likely you are to go ahead and counter, to appeal that denial.” (18:34—18:46)

“Ignorance is no excuse. And honestly, the bottom line, you're going to bleed a whole lot of money on the table if you don't pay attention.” (20:30—20:36)

“In my experience, although they say it’s a random audit, I don't think that's a thing. It’s an audit that is caused, triggered, by being unusual in your submissions. And the insurance companies view that very, very specifically, very succinctly. So, any kind of deviation. And as far as the audit goes, in today’s world, for example, that doctor who has done 50% surgical and 50% simple extractions, that is off enough that the insurance companies go, ‘There's something really strange going on here. We’re going to go ahead and do an audit.’ And if you're in-network, you're obligated, by the contract, to cooperate. If you're out-of-network, it takes a court order for you to be forced to participate. But if you don't cooperate, it’s going to change your life and your relationship with the insurance company out-of-network moving forward.” (23:02—24:00)

“Be aware that audits are probably not random, and there could be significant repercussions as a result of anything that they find inappropriate. And it doesn't mean that you've done anything wrong. It probably means that you haven't documented appropriately to substantiate the medical need for that surgical extraction. And for my coding geeks out there, you probably know one of two things have to happen to elevate a simple extraction to surgical. That would be either the tooth had to be sectioned, or number two, the bone had to be removed. And if the clinical record does document that and support it, then the insurance company can't say, ‘Well, I don't see anything here that supports that information.’ Your clinical record does. So, it’s a way of being able to put down a foundation that supports the billing and coding and supports and protects you moving forward.” (25:29—26:17)

“As far as insurance companies disposing of claims, I have not been witness to that. However, if there are issues in submissions, that may kick that claim out. So, if you've got a wrong identifying number, a wrong birthdate, generally, there's something that will cause that claim to drop. And insurance companies and the people that are working there are like everybody else; they are covered up. So, in terms of them working through those, it will be on the bottom of the to-do list because it is tedious and, ultimately, it’s not on their priority list.” (27:30—28:10)

“Make sure all the information is correct, that you're sending it to the right email address, or the clearing house has all the information in, and that the clearing house is actually moving those forward. Some of the clearing houses will actually scrub claims so that information that needs to be added [is put in] before they're sent off. And a lot of times, that information is not opened and reviewed by that person in the dental office that knows they need to provide this and such before it moves forward. It’s not lost. The insurance company may have never gotten it. Because with a good electronic clearing house, they need to scrub those. They need to kick out those that are not going to be paid because that's going to streamline the process.” (28:16—28:58)

“You need to pay very close attention, if [the insurance company is scrubbing your claims], to go back in and provide them the information they need to go ahead and forward that information to the insurance carrier. Because any small thing will kick it out. And there again, just like the letters and the emails from the insurance companies, you need to pay attention to those too. It may not be the insurance company. It may be something that the clearing house needs, or it may be something that the clearing house did go ahead and move forward, but it didn't have correct information. So, that drops that out, and it takes a much longer time for it to be processed.” (28:59—29:28)

“If you get that thing that says they haven't received it, if they're attachments, the electronic attachment will be able to be reviewed to find out if it was received, and when, and if it was opened. So, if they say that they didn't receive it, if you do a little bit of pre-preparation for that call to the insurance carrier that says, ‘We didn't receive that,’ you could go, ‘Uh-huh. No, you received it. Here is the EFT number attached, and this is when it was opened. So, would you like to go ahead and tell me again that you didn't receive that?’ You would be surprised at the number of times they go, ‘Oh. Um, uh, let me check again.’ And, ‘Oh, we did find it.’” (29:29—30:09)

“Be armed and dangerous when you're communicating with the insurance company. Be prepared. Don't be angry. It’s not going to help anything. Just be very matter-of-fact. And to be honest with you, the insurance companies do keep a track log. So, if you're that practice who will be the bulldog, if they have a claim that's kind of on the fence, it’s kind of like, ‘Eh, this could go either way,’ rather than denying it, they're going to go, ‘Oh, that's that office. We’re going to go ahead and process this because we’re going to have to work through all this to make sure that it does get paid.’” (30:10—30:45)

“One of the things that your general 42-year-old who is in practice does not know, with several of the insurance carriers, you can negotiate the fees. Now, that DSO has a huge number of doctors and it may be more beneficial, especially if they have a low volume of dentists in a particular area that are signed up for a plan. It may be important for them to do a little bit of negotiating with that fee to make sure that they do bring that group in, and they have a larger group that their patients can be treated by. But nothing says that you can't do the same negotiation.” (31:34—32:15)

“My grandmother, I love her to death. She passed away several years ago. Farm lady. She raised chickens and sold eggs to the grocery store, back in the day. And she negotiated everything. So, use that to leverage, and she could buy beef, hamburger, and they would give her a discount because she negotiated that. We have lost sight of being able to do that. We live in a world where things can be negotiated. And the fee schedule that's presented is the worst-case scenario. It’s like trading cards. They're going to come at you with an offer the least beneficial to you. And that's the starting point.” (32:41—33:20)

“I see insurance companies dictating treatment by what they reimburse. And that is scary. So, for example, when I do audits for practices, trying to help them get better at what they do, I'll see a notation in the clinical record that says, ‘X-rays are not due.’ And my hope is when I ask that person who made that entry, ‘What does this mean?’ that they're going to say, ‘Doctor reviewed the patient’s history, risk factors, and determined, at this point, the patient would not benefit from radiographs at this time.’ When I ask the question, ‘What does it mean, X-rays are not due?’ What do you think the answer is? ‘Insurance won't cover it.’ So, what is dictating the treatment for that patient? The insurance reimbursement. So, whether you want to admit it or not, you're allowing the insurance company to dictate to you how to treat your patients.” (34:46—35:44)

“If you're under that pressure where you are either modifying your treatment based on what the insurance is going to pay for or changing your documentation in your billing such that it doesn't meet standard of care in terms of legal, submitting those claims, you need to reassess and reevaluate. Because I can tell you, none of it is worth it. Do what's right. There's no good reason for doing the wrong thing.” (36:41—37:15)

“Documentation is going to help to maximize reimbursement, because it gives that billing person the ammunition they need to submit a claim that is bulletproof.” (37:56—38:07)

“Another thing that you need to understand is there are, as far as optional services and limitations in terms of what the insurance can limit you to, an insurance company cannot dictate to you the treatment that you provide the patient. Absolutely, it’s inappropriate. They can't do that, legally.” (38:09—38:27)

“Understand that negotiating this minefield that we have in dental billing and coding, there are ins and outs. And unless you are willing to do the work to learn and to implement systems that meet the requirements, because there are steps that you need to go through any time you're doing anything like this, like an optional service thing, you need to know your limitations, whether or not the insurance company will accept it. And the sweat equity that you put in prior to is going to help you be able to maximize that.” (39:24—39:58)

“I stress the word legitimate reimbursement. I want you to get every cent that you're entitled to, no more and no less, to do it in a way that is well-understood by all the team, and it protects and defends. I want to be the last person who goes to prison for things that they didn't know or understand.” (39:58—40:14)

“If you haven't dipped your toe in medical submissions, I encourage you. If you're going to do submissions for your patients, be aware that there are services that we provide that could be covered under medical — and the reimbursement is much better. So, start. If you haven't started doing that, I would encourage you, over the next 12 months, dip your toe into that. Start becoming more familiar with it, because we’re going to see that trend continue moving in that direction.” (48:09—48:34)

“The insurance companies can't pick and choose. If it’s medically necessary, if it’s covered under the plan, you submit the claim and the claim is correct, they're obligated by contract to pay that. They can't say, ‘Oh, no. Just don't feel like paying that today.’ No, if you meet the criteria, and the patient meets the criteria, and there is a legitimate medical cause for the dental issue that you're treating, yeah, it’s pretty consistent, as far as the coverage goes.” (49:16—49:42)


0:00 Introduction.

2:27 Dr. Shelburne’s background.

7:13 Why insurance companies like clean claims.

10:05 Read your contracts.

11:24 Where trends in reimbursements are at today.

15:16 How to play the game of shared agreements.

18:06 Learn to read the EOBs.

20:58 What to know about insurance company audits.

26:41 Things to know about reimbursement.

31:11 You can negotiate fees.

34:10 Reimbursements dictate the treatment.

37:15 Missed opportunities with reimbursements.

40:16 What dentists get wrong about reimbursements.

44:05 Slowing participation with less desirable insurance.

46:50 Last thoughts on insurance reimbursement.

50:21 More about Dr. Shelburne and how to get in touch.

Reach Out to Dr. Shelburne:

Dr. Shelburne’s website:

Dr. Shelburne’s Facebook:

Dr. Shelburne’s social media: @2thdoc55

Dr. Roy Shelburne Bio:

Dr. Roy S. Shelburne, DDS, is a 1981 Honor Graduate from Virginia Commonwealth University’s School of Dentistry. After graduation, Dr. Shelburne opened his practice in his grandfather’s old hardware store. He has served as president of the Southwest Virginia Dental Society and has volunteered at Virginia’s various MOM projects across the state. He has also served as a short-term missionary to Honduras with Baptist Medical Missions International.

Some dentists may fear litigation, but few worry about going to prison. On October 24, 2003, the FBI broke down the back door of Dr. Shelburne’s office and confiscated all of his business and dental records. Over the course of the next three years, every aspect of his life was subjected to the closest scrutiny. He was indicted in October of 2006. In March of 2008, he was found guilty of healthcare fraud, racketeering, and money laundering, and spent 19 months incarcerated at the Federal Prison Camp in Manchester, Kentucky, before his release in 2010.

During the investigation and trial, it became apparent that his records, billing, and coding systems were faulty, and that ignorance is no excuse. While incarcerated, Dr. Shelburne had ample time to reflect on his life and found that true release comes when we draw from our strength, character, vision, wisdom, and experience. A speaker, consultant, and writer, he now specializes in records keeping and business systems that protect and defend other doctors from facing the same troubles.

456 episoder