Managing dental insurance can be challenging when you’re dealing with multiple insurance companies and state-run plans like Medicare and Medicaid. Each insurer and plan has defined their own requirements for submitting claims, accepting CDT codes, and attaching documentation for dental procedures.
Keeping up with changes in these plans takes up time and overwhelms your staff. Plus, a single mistake in billing can cost your practice reputational risk, legal penalties, and thousands of dollars in lost revenue! But, we’ve got a solution for that. In this blog, we’ll discuss rules, regulations, claim filing deadlines, and other best practices for compliant dental billing services to protect your practice and revenue.
So, let’s get started!
Why is Dental Billing Compliance Important?
Dental billing compliance is the process of following federal, state, and insurance companies’ rules for submitting dental claims. Complying with these policies not just secures claim reimbursements, but also protects your practice on legal grounds, maintains your credibility, and builds trust between your practice and your insurers.
For proper compliance for insurance claims, make sure that:
- CDT codes are accurate
- documentation is complete
- prior authorization request is submitted(for certain treatments)
- claims are submitted within deadlines
- patient information is accessed securely
And to bill patients for dental treatments, follow ethical and legal practices, which include:
- Verifying patient expenses on time
- Communicating clear costs to patients
- Providing written estimates on expenses
Dental Billing Requirements Your Practice Must Follow
HIPAA Compliance
The Health Insurance Portability and Accountability Act is a federal law, which requires healthcare practices to protect sensitive Patient Health Information (PHI). HIPAA ensures that patient data is transmitted easily for electronic claims, and requires that all these records must be stored and maintained in fully secure EHRs or tools.
A practice can face several penalties if it violates HIPAA policies. Penalties start from $100 and extend up to:
- $50,000 in fines and 1 year in prison for basic violations
- $100,000 in fines and 5 years in prison for sharing data under false pretenses
- $250,000 in fines and 10 years in prison for sharing information to gain profit or cause harm
So, whether you’re billing in-house or outsourcing dental billing, make sure that your staff or billing partners use secure systems to access patient details and submit electronic claims.
Implement some policies to maintain HIPAA compliance in your practice, such as:
- Controlling access for viewing and sharing patient data only to authorized staff members
- Signing Business Associate Agreements with third-party billing companies or dental billing software vendors to hold them to the same HIPAA standards you follow
CDT Coding Standards
Your staff should follow the CDT coding fundamentals to select codes for dental procedures. They should check the American Dental Association (ADA)’s CDT code updates, in which ADA:
- Modifies existing codes
- Adds new codes
- Deletes outdated codes
They must also review their insurer’s policies for accepting CDT codes. Insurers may not accept codes for procedures which they don’t find necessary, and bundle some codes into one to control costs.
Example: A practice submits a claim using different codes for a comprehensive exam, X-rays, and a fluoride treatment. However, if a fluoride treatment isn’t medically necessary for the patient, the insurer bundles the comprehensive exam and X-ray into a single code, and denies reimbursement for fluoride.
When your staff is coding procedures, they must avoid the following mistakes:
| Coding Error | Description |
|---|---|
| Duplicate billing | Same claim submitted multiple times due to system glitches or other errors. |
| Upcoding | Billing for more expensive procedures than the actual treatment performed. |
| Unbundling | Separating dental procedures that should be billed together. |
These errors can lead to fraud allegations and legal complications that:
- Damage a practice’s reputation
- Impact patient trust
- Result in penalties
The best practice is to:
- Train your staff on CDT codes
- Check codes before submitting claims
- Consult the CDT manual
All that makes sure that codes are accurate for clean claim submission and dental billing compliance.
Timely Filing Requirements
Insurance companies set their own deadlines on submitting claims after you perform a dental procedure. If you don’t submit the claim within that deadline, insurance doesn’t pay for that procedure. Some insurers set a 90-day filing limit, while others extend it to 180 days or even 365 days. The same rule applies in Medicaid plans, where each state has its defined filing limit to submit a claim.
And insurers also set deadlines for submitting appeals if a claim is denied or underpaid. So, you must submit appeal requests within insurers’ deadlines.
So, whether your staff submits claims and appeals manually, or uses dental billing software, they should track payer policies and process claim submissions within the deadline.
The best approach here is to submit claims as soon as you perform a treatment, and monitor claim progress regularly, so you can submit an appeal immediately after a claim is denied.
Reliable billing partners like TransDental help you with that. TransDental processes claims within 24-48 hours of the treatment, and quickly recovers your insurance payments. It also tracks overdue balances and submits claims fast to reduce A/R.
Prior Authorization Requests
Insurers require you to request approval for costly and high-risk dental procedures, before submitting claims.
A few examples include:
- Crowns
- Dentures
- Implants
- Oral surgery
- Scaling and root planing
Insurance companies mention the list of procedures, for which they require pre-authorization, in their provider manuals or online portals. They also list down the documents required for each procedure to prove medical necessity, and review the details before submitting claims.
If you ignore pre-authorization on these procedures, insurers can deny your claims, and recovering payments from patients isn’t an easy task!
Educate your staff and update your software, so your systems notify you on pre-authorization requirements. This approach prevents claim denials and secures your revenue.
Documentation Requirements
Insurers require dental practices to submit needed documents with a procedure to complete a claim submission. So, make sure that you attach all the documents with your claim form according to payer requirements.
Your documents help insurers learn everything about a patient’s condition, complaint, diagnosis, treatment, and follow-up.
Here, in the table below, we’ll have a look at some documents which insurers commonly require for dental billing compliance:
| Document | Description |
|---|---|
| Clinical or treatment notes | Brief notes that describe a patient’s evaluation, treatment, and progress. |
| X-rays or radiographs | Visual evidence that helps diagnose a patient’s dental condition and provide evidence for procedures like crowns, extractions, fillings, and root canals. |
| Intraoral photos | Dental images that give a clear view of the patient’s mouth. These help dentists diagnose a condition and insurers review it to justify claim reimbursement. |
| Periodontal charting | A graphic chart which documents a patient’s gum health for treatments and periodontic claim submissions. |
| Narrative | A brief document that describes details of a treatment and helps insurers learn why a procedure is necessary. It includes key details like diagnosis, treated tooth, performed procedure with CDT code, and date of treatment. |
| Prior authorization letter | A letter in which dentists provide insurers with the details of a dental procedure, along with a patient’s condition, diagnosis, and the necessity to perform the service. |
Note: Each payer and state has their own criteria for documents needed for a dental claim. Some documents like narratives and pre-authorization letters are required only for certain procedures.
For example, insurers require pre-authorization requests for costly treatments like bridges, so your billing staff must send the letter and get insurers’ approval before filing a claim.
No Surprises Act
The No Surprises Act requires that practices must not charge any extra costs to patients without their consent or knowledge, especially if a treatment isn’t covered by the insurance. The purpose of NSA is that you shouldn’t issue huge bills to patients, which they aren’t expecting.
Real-time dental insurance eligibility verification helps your practice comply with policies like No Surprises Act. It also prevents billing errors.
By verifying in real-time through automation, you get all the details of a patient, including:
- Patient demographics (name, date of birth, ID number, etc.)
- Insurance data which confirms if they’re verified by a plan
- Coverage plan, which informs about the available benefits and frequency limitations in insurance
With that, you know what insurance covers and what the patient needs to pay.
As a result, you can inform the patient about their responsibilities like co-pays, deductibles, remaining charges, and non-covered services, before the treatment even begins.
It improves your relationship with patients, as they trust you, and are prepared to make a decision according to their budget and clinical needs.
As a result, you can charge them on the counter, or offer them flexible payment plans if they can’t afford expensive treatments. It makes patient billing and collection smoother for your staff, and efficient enough to recover your dues soon.
Medicare and Medicaid Dental Policies
Medicare and Medicaid dental policies are different for each state, so you should consult your state’s Medicaid policies for dental billing compliance. For example, California’s state program Medi-Cal Dental requires providers or authorized staff members to submit live signatures on claim forms.
However, there are some federal laws, which apply nearly in every state. These are:
| Policy / Rule | Description |
|---|---|
| False Claims Act | A federal law which penalizes practices for submitting wrongly billed, overcharged, duplicate, and unsupported dental claims. |
| Anti-Kickback Statute | This law states that dental providers must not offer or receive anything of value for referring patients to enroll in any federal policy. |
| Stark Law | In this law, healthcare providers can’t refer patients for diagnostics or other treatments to a dental practice or facility which they own themselves. |
| CMS Regulations | Practices must follow CMS regulations for submitting claims, requesting pre-authorization, checking CDT codes approved by their state policy, and attaching documentation. |
| Record Retention | Providers must retain the documentation and all records of a patient’s treatment for a specific number of years as defined by state law, commonly three, five, or seven years. |
You must follow your state laws to avoid fines and legalities for violations, which can cost your practice thousands of dollars!
Best Practices for Dental Billing Compliance
Let’s discuss some practices through which your providers and staff can comply with policies, so your billing is free of errors and helps maximize your collections.
Negotiate Fee Schedules
Proper fee schedule management and negotiation help your staff learn about the reimbursement rates you’ve set with insurance companies, and bill the right amount to insurers for each procedure.
It protects your practice revenue and prevents any legal issues, as charging less for a procedure decreases your profits, and charging more makes you prone to allegations of fraud.
Well-structured fee schedules also support your appeal requests if you’re paid less than the contracted fee. You can appeal correctly by mentioning the set fee for a treatment and document your structure for reference. Chances are that insurers approve your request and reimburse the fair amount.
So, make sure that your staff and insurers properly understand your fee schedules.
Maintain Healthy Relations with Insurers
If you establish strong relations with insurance company representatives, it helps a lot.
You can contact them anytime for your queries, whether it’s for:
- Verifying a patient’s insurance coverage
- Tracking your claim progress
- Staying updated about latest policies for compliance
Real-time information on patient coverage and claim progress makes your dental billing process accurate and quick.
Perform Dental Billing Audits
Billing audits protect your practice from legal issues, external investigations, and revenue loss. By auditing your finances and billing practices, you can find weak areas which need improvement. These may include incorrect coding, missing pre-authorization requests, incomplete documents, and other billing errors.
When your staff improves these weak points, they can process clean billing, which helps you comply with regulations and recover your dues fairly.
Train Your Staff on Billing Compliance
Your billing staff handles all the aspects of the dental insurance claim management, whether it’s submitting claims, tracking progress with insurers, and appealing for denials or underpayments.
They must be trained enough to perform all the billing tasks efficiently and make sure that they’re complying with policies.
So, set up training sessions, so your staff is aware of existing policies and latest updates. Also provide them with training manuals and materials that educate them, and are easily accessible whenever they’re submitting claims.
In the table below, we’ll explore some manuals and materials that help your staff with dental billing compliance.
| Training Material / Manual | Description |
|---|---|
| Dental Billing Compliance Manual | A document explaining billing rules and regulations, payer expectations, and compliance standards. |
| ADA CDT and Coding Companion Kit | A kit featuring a complete list of the latest CDT codes and guidance for coders to accurately code procedures. |
| Insurance Contracts and Fee Schedules | Agreements with insurance companies that define covered services and set reimbursement rates for procedures. |
| Payer Provider Manuals | Books or online resources detailing each insurer’s billing rules, documentation standards, and procedure-specific requirements. |
| Prior Authorization Guidelines | A list of procedures requiring insurer approval, along with instructions on how to submit authorization requests. |
| Clinical Documentation Standards | Guidance on required notes, images, charting, and supporting documents needed for procedures and claim submission. |
| Claim Submission Guide | A step-by-step explanation of preparing, reviewing, and submitting dental insurance claims correctly. |
| HIPAA & Data Security Regulations | Rules and guidance on accessing, using, storing, and protecting patient data to remain compliant with HIPAA. |
| Denial Management and Appeals Guide | Instructions for reviewing Explanation of Benefits (EOBs), correcting denied claims, and submitting effective appeals. |
| Coordination of Benefits Guide | Guidelines for identifying primary and secondary insurance when patients have multiple plans and submitting claims in the correct order. |
Invest in Latest Technology
Technology is evolving and your practice must adapt to it, if you’re not already using it. It’s important to stay ahead and make your dental billing smooth, clean, and compliant.
Use a top dental billing software, which adapts to your practice’s billing processes, and offers all key features, like eligibility verification, integration with your practice’s EHR and payer portals, dental imaging, patient payment portals, and claim submission, in one place.
You can also invest in solutions like TransDental’s robotic process automation, which manages your entire dental revenue cycle. RPA technology performs billing tasks faster and more accurately than outdated systems or manual processes. It flags and corrects billing errors, delivering results you want.
Outsource Dental Billing
Contacting insurers to monitor claim progress, learn compliance requirements, and submitting and tracking appeals takes much of your time. Similarly, training your staff to efficiently perform billing tasks, also requires you to invest in costs and resources.
The question looms: What if your practice could submit clean claims for dental billing compliance without investing your time, effort, and resources?
You can achieve that by outsourcing your dental billing and coding to partners like TransDental, who:
- Supports your staff by working with them
- Lets them relax and focus on clinical tasks
- Knows Medicaid, Medicare, and commercial payer rules very well
- Negotiates with insurers
- Integrates with your practice EHR and payer portals smoothly
- Stays HIPAA-compliant by securely accessing patient data
And TransDental charges you very less for compliant billing! The amount is just a minimum percentage of your amount recovered from insurance claims and outstanding patient bills.
The combination of AI technology and certified billers and coders performs these tasks efficiently, submitting your claims fast, and delivering accurate results.
Conclusion
Staying compliant with rules and policies protects your practice from revenue loss, legal complications, and reputational damage. Integrate payer policies to submit compliant insurance claims and patient bills, which ensures that you earn fairly for dental services rendered to the patients.
If your staff finds it difficult to learn and follow regulations, the best practice is to choose an experienced and trusted billing partner for dental billing compliance.
Frequently Asked Questions (FAQs)
What are the main federal regulations for dental billing?
Dental billing is mainly governed by regulations like HIPAA (patient data privacy), the False Claims Act (no incorrect or inflated claims), Anti-Kickback Statute, and Stark Law (no improper financial incentives). If you bill Medicaid or Medicare, CMS rules also apply, especially around documentation, coding accuracy, and medical necessity.
What are the common dental billing compliance issues to avoid?
The common compliance issues are upcoding or unbundling, missing or weak documentation, billing for services not covered, failing to verify eligibility, and poor handling of patient data. Many practices are also affected by outdated CDT codes or ignoring payer-specific rules.
How to ensure dental billing meets federal compliance standards?
TransDental complies with state-specific compliance regulations, so your claims are submitted and reimbursed according to Medicaid and Medicare dental policies, without risking revenue loss, penalties, or legal complications.
Which are the top dental billing services that guarantee compliance with regulations?
TransDental’s billing services comply with all state or payer policies, whether you submit Medicaid/Medicare claims, or deal with commercial insurers like Aetna, Cigna, Blue Cross Blue Shield, and Delta Dental. Our AI technology and billing experts implement your state/payer regulations in billing processes and process claims accordingly.
Where to find dental billing compliance training for staff?
You can arrange in-house training for your staff by assigning experts for the task or enroll trainees in courses provided by ADA, AAPC, and HIPAA training providers.
