Make Friends With Benefits by Tina Byrne

Make Friends With Benefits 

Recapping the factors that could be draining insurance reimbursement payments from your practice

by Tina Byrne

Optimizing patient benefits management and maximizing practice profitability requires careful attention to key factors. Any single issue—and frequently a combination of multiple factors—can lead to revenue loss and customer service issues. These factors include team development, streamlined processes, and a well-informed and strategic approach to insurance contracting.

Team development

Insurance coordinators generally have a restricted understanding of patient benefits and receivables management. In addition, it’s common for established practices to maintain methods and processes that have been in place for more than 20 years. To optimize profitability and effectively manage patient benefits, it’s crucial for the entire practice team to be well informed and up to date on the ever-changing aspects of insurance billing and reimbursement.

Offices continue to use verification processes that involve obtaining three or four pieces of information about the patient’s benefits. However, in today’s context, it’s often necessary to possess knowledge of 10 or more pieces of information regarding a patient’s plan. I can affirm that a substantial number of insurance issues in an office can be attributed to a failure to inquire and adequately prepare by having complete benefit information before presenting treatment and precrediting insurance amounts on contracts.

A key foundation for success in this area is providing comprehensive education and training to staff members. This includes equipping them with the necessary skills in coding and documentation guidelines, and ensuring a thorough understanding of insurance policies and procedures. By investing in continuous education and offering resources for development, a practice empowers its team to navigate the complexities of insurance systems with greater efficiency and effectiveness.

Establishing streamlined and efficient processes within a practice is crucial for managing patient benefits and optimizing profitability. This involves developing standardized workflows for patient registration, eligibility and verification; accurate calculation of benefits based on the provisions and restrictions within the plan; precise coding on claims; monitoring the timely receipt of insurance benefit payments; carefully reviewing the details of each explanation of benefit (EOB) advice received; and promptly responding to and addressing unpaid benefit situations. In addition, it is invaluable to leverage technology solutions, such as carrier online portals and practice management software functions, to automate tasks and streamline communication with insurance providers.

Many team members depend solely on insurance aging reports to track and monitor benefit payments; unfortunately, these reports often prove to be inaccurate. To ensure the utmost accuracy and reliability, it is crucial to consistently review and update the aging of insurance accounts. As payments are received, the date(s) for upcoming payments should be placed into ledgers accordingly. If your report indicates carriers have paid ahead (you’ll see a negative number in the aging column), it’s not being aged properly, because insurance never pays ahead for benefits. The frequency of benefits could also be a factor for the inaccuracy. This proactive approach is essential for maintaining competence in managing insurance payments and benefits.

If your office heavily relies on the bottom-line numbers provided by insurance aging reports, I strongly recommend conducting regular audits to assess their accuracy. By doing so, you can ensure that your financial data remains trustworthy and dependable.

An informed and calculated approach to insurance contracting plays a significant role in ensuring a practice’s profitability. This involves evaluating and negotiating contracts with insurance companies to achieve favorable reimbursement rates, contract terms and patient coverage. By thoroughly understanding the financial implications of different insurance contracts, a practice can make informed decisions about participating in specific networks or negotiating alternative reimbursement models. Additionally, staying informed about industry trends, regulatory changes and market dynamics allows a practice to adapt its contracting strategies accordingly.

While these factors are discussed separately, it is important to note that their order of priority may vary depending on the unique circumstances of each practice. Some practices might prioritize team education as the initial step to build a knowledgeable workforce, while others might focus on implementing efficient processes first to optimize revenue cycle management. The key is to recognize the interdependencies of these factors and tailor their implementation to the specific needs and goals of the practice.

Within our organizations, we are able to maintain full autonomy over team training and the ongoing improvement of our systems. We should proactively identify any areas in need of improvement and consistently assess their effectiveness and efficiency. Conversely, external factors lie outside our sphere of influence and are often nonnegotiable. Nevertheless, there are situations where we have limited power to alter these external factors, so it becomes imperative for us to embrace a strategic approach that enables us to harness any advantages presented by these external factors for our own advantage.
Dental insurance reimbursement
Fig. 1: 2022 averages

Dental insurance reimbursement
Fig. 2: Conversion rate

Comparing benefits and fees

Based on statistical data, 60%–70% of the population has dental benefits, and out of those benefits, around 96% are classified as some form of managed care, with the majority consisting of PPO plans. Insurance providers are progressively enhancing the benefit amounts available for treatment received from in-network providers while reducing those for out-of-network. They are also implementing a combination of proactive and reactive strategies to educate and inform their subscribers about the numerous benefits and advantages associated with receiving care from providers within their network.

Interestingly, data provided to me from a study conducted by OrthoFilooked at average fees for practices with in-network participation, along with the average benefit for the patient. As you see in Fig. 1, the benefit is a little higher for in-network, but the average fee for the practice is $400 lower.

The study also compared the conversion rate for patients without insurance, with in-network insurance, and with out-of-network insurance (Fig. 2). Two takeaways:
  1. Patients with insurance coverage are significantly more likely to start. In previous research, OrthoFi discovered that the amount of coverage is not material; as long as the patient knows they have some coverage to lower their out-of-pocket, their conversion rate is higher. It’s like a coupon burning in their pockets.
  2. The conversion rates of in-network practices and out-of-network practices are virtually identical. That means that being in-network has no advantage in terms of converting the exam. OrthoFi also looked at the kept new-patient exam (NPE) rate—kept exams vs. scheduled—and found a small one-to-two-point lower rate for out-of-network, which likely is not statistically relevant.
What this doesn’t show is whether the phone rings more for in-network practices (i.e. patients are finding them via the carrier site listings). Given average start totals for the cohorts is equivalent (slightly favors out-of-network), I would discount that. But to date, we can’t know with certainty.

OrthoFi concluded that being in-network costs a practice about $400 in net production, for no meaningful gain in terms of kept NPE or conversion rate. There are exceptions, such as Delta Dental, because of its policies mandating that if practices are not in-network Delta cannot accept the assignment, and we know accepting assignment is a conversion factor. There also are some exceptions in terms of dominant local employer plans, such as Disney in Orlando, Florida, and Walmart in Arkansas. But this is an important finding, because carriers are pushing harder to get more in-network providers while also increasing in-network discounts. This helps practices fight back and be more selective.

Take inventory, then take action
Providers frequently make hasty decisions to start or end contracts with insurance carriers, driven by factors like the practice’s current state, significant discounts and sometimes team frustrations with the processes. While some practices believe team development is the only answer, I find that positive transformation frequently indicates a need to address internal processes and contracting, whether it’s the initial engagement or revisiting participation.

Ask yourself the following actionable questions to determine revenue drain in your practice:

For in-network practices:
  • “Have I contracted with a fee schedule that allows for the highest allowable charges?” Many carriers, except for a few major ones, can be contracted through another carrier or a third-party administrator’s network.
  • “Am I using all available coding and claims submission methods for my treatments?” This strategy could potentially reduce discounts under specific plans and provide greater allowances. Offices often fail to set up systems to assess discounts by individual carriers. Consider making changes to your system to make informed decisions.
For out-of-network practices:
  • “Am I losing patients to nearby offices that are in-network with specific plans?” Assess your metrics to understand the situation. I have observed this happening in numerous offices I’ve worked with, especially now that carriers are significantly reducing benefits paid to out-of-network providers.
  • “Should I consider contracting with PPOs if I can maximize my allowances by itemizing the codes in my treatment plan?” If being a noncontracted provider is negatively impacting your practice, it would be wise to take a strategic approach and explore your options.
From an operations standpoint, visit the following areas that can be improved upon:
  • Reports. Begin by conducting an audit to evaluate the accuracy of your insurance receivables. If this hasn’t been a standard protocol in the past, it’s important to do so now. Often, offices discover significant credit balances on their insurance ledgers. Reviewing your insurance reports will give you a clear understanding of the situation and help identify any inaccuracies.
  • The end-to-end process. It’s crucial to revisit your entire process for handling insurance benefits. This area tends to be one where the doctor has the least knowledge. Seek feedback from your team. Assess whether you have enough benefit information from your verification process. Identify any recurring issues that could be minimized by making necessary changes to your procedures.
  • The team’s comprehension. Assess the level of knowledge and expertise your team possesses regarding insurance and the execution of the insurance process. Unless your staff members are seasoned and resourceful individuals, chances are they may not be well-versed in this area. Consider providing additional training and resources to ensure that your team is well-informed and capable of efficiently handling insurance matters.
To enhance the overall operations and efficiency of your practice while minimizing revenue loss from insurance, focus on addressing key areas for improvement.

Author Bio
Tina Byrne With more than 40 years of experience working and consulting in the field of orthodontics, Tina Byrne has gained success and recognition for her proficiencies in clinical, business and administrative functions. She has extensive knowledge and understanding of systems innovation and efficiency, data analysis, strategic business planning and marketing implementation. Byrne, who has lectured and helped guide the success of leading practices throughout North America and abroad, is the only industry consultant who has extensively trained and lectured on orthodontic insurance. Email:

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