064: 2025 Dental Insurance Mistakes

In this episode of 'No Silver Spoons,' Sarah Beth Herman dives into the common challenges dental offices face with insurance and shares practical advice to overcome them. She emphasizes the importance of updating CDT codes, verifying umbrella plans, and maintaining a structured follow-up schedule for claim statuses. Through real-life examples, Sarah highlights how outdated codes and verification mistakes can lead to costly claim denials. She also stresses the need for ongoing staff training and accurate documentation. Sarah reassures dental practices that help is available and encourages them to take proactive steps to improve their billing and operations. Tune in for valuable tips to make your dental practice run smoother!

Chapters

• 1:41 The Struggle with Dental Insurance
• 3:05 Training and Staying Updated in Dentistry
• 4:06 Real-Life Example: SRP Claims in Limbo
• 6:42 The Full Mouth Debridement Pitfall
• 7:30 What’s New with CDT Codes in 2025
• 8:14 The Power of Umbrella Plan Verification
• 11:26 Timing is Everything: A 10-20-30 Follow-Up Rhythm
• 13:04 Avoiding $0 Billing Pitfalls

Transcript

 Hey friends. Welcome back to No Silver Spoons. I'm your host, Sarah Beth Herman, and today I'm talking to dental offices, and you guys know that every month I try to throw in a few episodes that are just about dental. Now, if you're in any other business, maybe you wanna listen to this episode because I talk business strategy.

And yeah, I give a lot of information on what's going on in the dental world, but. Uh, really, so many of my followers are just in the dental industry, and so I wanna cater to you, but I know I have some new friends here that aren't in dentistry. And hey, if this episode is not gonna resonate with you, go check out one of my other episodes.

I'd love to just catch up with you and trust that you guys are going to learn something brand new today. So let's just get right into it. Today, I wanna talk about. Something that I am seeing dental offices struggle with every day, and I don't think that there is any sort of end in sight for when this struggle will go away, but every time I come on here and I'm talking to you, I want you to know that I support you and I see you, and I know that you need advice and wisdom and things outside of your own circle to help influence you to handle this better.

What am I talking about? Insurance, dental insurance, and I know there's a huge stigma of people just against dental insurance altogether. I think there's a time and a place for it. I think there are some reasons it's really helpful, and I do think that there is a battle that needs to be won versus dental offices.

But hey, you know what? Let's just try to get as much on the same page as we can and talk about ways we can be better together. This episode is actually based on training that I just did for my own team here at Dentistry Support. We covered everything from rehashing CDT codes that were updated in 2025, umbrella plans, claims, status, rhythms, and now I'm bringing this all to you because I don't think that.

We realized how often we actually need training. Like we just think, hey, I've been doing this forever, so it doesn't matter. I already know everything. But the reality is we don't, I. We don't always know everything. We don't always understand everything. We're not always the best at everything, and so we need to place and position ourselves in other circles in earshot of new and different people all the time so that we can become better versions.

So, whether you're a practice owner, a dentist, an office manager, a treatment coordinator, or a biller who's doing it all, this episode is for you. So, let's get started. First, I wanna tell you about a GP practice, a general practitioner practice that I worked with earlier this year. They came on board with us, and they let me know ahead of time that they had a ton of outstanding ar.

They were coming from another third-party company that had worked with them for 10 years. This is one of the longest standing. Virtual billing companies that exist. I won't name their name, but they had been working with them for 10 years. Their outstanding AR was really long, and they weren't getting the results they needed.

They were constantly having their cha, their teams switched up and so finally they left that company. They came to us, and we started researching their claims. We learned a lot about their billing breast practices just by going through their claims, and we were noticing a ton of claims were being denied for SRP procedures.

After getting into it, they were still using an outdated code when they were submitting them, and they weren't attaching Perio charting. The office just assumed that their CDT codes auto updated every year, but it didn't. So, they had about $6,000 in claims just for SRPs that were sitting in limbo. They had a ton of claims that were denied for x-rays just because of frequency limitations.

But what should you do in your office? Like how do you do it? How do you make sure, scratch that. What should you do in your office for the ones.

Scratch that. Let's just break this down for a minute. Like I'm already looking at this office and they've got $6,000 in claims sitting in limbo for SRPs, a laundry list of claims that are denied due to frequency limitation. So, what should you do in your office? Always manually confirm that your software has updated CDT codes every January.

Yeah, sure. Sure. But more importantly, you should know them. So, I think that you should check your system in January every year, update it, then review any templates in your system to make sure that attachments and narratives are going out correctly. I think that you should make sure that every piece of claims that your office touches from insurance eligibility to the outgoing billing.

Is all double checked at the beginning of every year and then check it quarterly. Don't assume trust but verify. That is a statement we use all over the place here at Dentistry Support. And so it's really important that everybody understand trust, but ve trust, but verify. Teach your team to know where to go to get what they need.

But just double check it, right? So another example from one of our offices, they submitted a full mouth debridement, a D 43 55, and a comprehensive exam because it was a new patient on the same day. Sounds normal, right? Well, actually that claim was denied and maybe some of you were listening to that and you already knew.

CDT has clarified now that a full mouth debridement must be followed up by a comprehensive exam. Not done on the same day. So maybe you already knew that, but maybe you didn't. Maybe you were thinking it's on new patients. If they come in for an oh 1 5 0 and we have to do a full mouth debridement, we bill both.

Yeah. Well that's been changed. So, so what are we doing now? Right, so this update was one of many that happened this year. For example, the 0 3 5 6 CBCT with treatment plan, the D 8 6 76 ortho visit with jaw surgery and the D 9 9, 9 8 treatment plan coordination. I mean, what we have codes for these things now, like what's going on?

So if your billing team isn't reviewing these updates, you're gonna see rejections pile up. So a quick tip I have for you. Make sure that your team has the 2025 CDT code book printed, or maybe you have it, that you could have ordered it from the CDT. Whatever it is, printed it, highlight it, reference it regularly, especially the codes that are being used often in your specialty or in your practice.

I spoke with a front office team just the other day actually, that had a full hygiene schedule, but they ended the month with the lowest collections in a year. And so a lot of times when people tell me that initial statement, 'cause I hear it all the time, you know, it's all about knowing why, like what happened to get you there.

And oftentimes they tell me, I don't know Sarah Beth, I don't know what happened. But with this particular office, their eligibility team didn't catch that multiple new patients had BLE, had umbrella plan issues. They were verified under the wrong networks, and the patients ended up with out of pocket expenses without even realizing it.

Several ended up walking out without even completing treatment. One office said they had a bad review on Google because of it. For your office, I want you to start building a list of the known umbrella networks and their common aliases. Make this a living document and share it across your team. A great place to do this at would be in Google Docs because anybody can edit it simultaneously.

Anytime you discover a new connection like Guardian using Aetna or Cigna linking with Connection Dental, add it to the list and don't hesitate to confirm with the rep. Train your team to say. Before I finish this eligibility verification, can you confirm if this group number is administered by another plan?

I mean, that is a simple one-liner when you're on the phone with the insurance company. Here's another story. A patient came in with a guardian card and the front desk verified benefits through guardian directly, but didn't realize the plan was administered by Aetna PPO. They told the patient they were outta network.

The patient walked and didn't come back. Lesson always ask, is the plan administered by another network? Always ask, is the plan administered by another network? Look up the group. Um, look up the group. P, scratch that. Look up the group number. Use the portals. Don't assume what's on the card is the full story.

If you're a verifier, you are the gatekeepers here. When you get it right, you protect the schedule. The doctor's chair, the chair time, the patient experience, the front office getting yelled at. You guys are the gatekeepers, so you gotta get it right. One of our clients, one of our dental practices, was waiting on over $40,000 in outstanding insurance plan.

One of our dental offices was waiting on over $40,000 in outstanding insurance payments when we audited their claims. Most of them were over 30 days old, of course, but this 40,000 was in 120 days old. Now when a client comes to us, dental office comes to us and they want to have services, we really try to talk them through what that looks like, like how we'll work on their claims and what our expectations are of their practice.

Once we have cleaned up their office, and oftentimes we see our offices come to us with a lot of claims aging over 30 days, over 60, 90 and 120. Now, most of the time when there are claims aging over 30 days, it's easy fixes like one claim missing a provider, NPI, another one missing x-rays, maybe one stuck in the clearing house, maybe one stuck in a clearing house error loop.

No one following up because there wasn't some sort of structured cadence or claim follow up. So what we try to teach our offices is that, hey, if you only want us in your office for a little while to clean things up, that's perfectly fine. But when you don't have expert billers that are on staff or a third party company like dentistry support in your office, you often don't have those rhythms, those cadences for how follow up is happening.

And so we encourage you to implement a 10, 20, 30 rhythm. Create a spreadsheet or a task in your dental software, or even a handwritten log, whatever works for your system, but follow up every 10 days without fail. Payment is a result of intentional follow up, not hope. Maybe make that a little sticky note in your office.

Payment is a result of intentional follow up, not hope. Starting in April of this year. Our company's standard is that every insurance claim gets a status check every 10 days after submission. We previously were at every 14 days, but this means that now our claims are researched at day zero. They're sent at day 10.

The first status check at day 20, the second status check at day 30. Final check. Why does this matter? Well, most claim delays are fixable earlier, waiting over two weeks between waiting over two weeks between checks, let's problems fester Instead, we're staying proactive. We're getting our offices paid faster and we're reducing the chaos.

Office managers listen closely. This one, change will drastically reduce your age Claims. You won't see claims aging over 30 days because you will have cleared it all out way before you ever get to that 30 day mark. We also had an office recently submit $0 for two limited exams. They performed during a promotional event that they had.

The intent was good. They didn't wanna charge the patient, but the issue was that they billed the insurance with $0 too. Their payer system flagged a practice for unusual billing activity triggering, triggering a delay on all future claims for over six weeks. What, what are you kidding? Like why are, why, why?

So instead, always enter your normal fee, then use the claim note section to clarify. Submitted for documentation only. Patient not charged. This keeps the claim clean, compliant, and prevents the entire practice from being flagged. Teach your team that $0 is never the answer, not for documentation, not for favors, not for insurance.

When you submit a code for documentation only and enters zero or zero fee in the charge field, you are gonna be setting off a landmine in your practice. Payers and clearing houses may flag the claim for abuse or miscoding. Some auto deny others. Send your office an internal audit funnel. Others send your office into an audit funnel.

So instead, submit your usual and customary fee, the UCR. And in the notes, just write submitted for documentation only, not billable. This is gonna keep your claim clean and reduce your risk of getting flagged in the payer systems. It's not just about what happens in your office. Before we wrap up this episode, I just wanna say this, many of the offices that we've shared about today are brand new to working with us.

So whether they join dentistry support back in January, or they just came on board last month, they're facing different challenges that we are overcoming. That we are overcoming one step at a time. So if you're listening and thinking, that sounds like my office, you aren't alone and you're not behind, we will meet you where you are and level you up.

We also know that your office is busy. You're juggling schedules, patients emergencies, everything in between. So if this episode felt like a lot, or if you're feeling like, gosh, how will I even begin implementing this? It's okay. We are here to help. You can give us a call and we wanna chat it out. We wanna workshop with you and help you find a rhythm that works for your office.

No pressure to enroll in support, but more so just you knowing you have someone on your side that can workshop challenges you have. So let's recap what we covered today. The CDT 2025 updates are live. They've been live for a few months. Now check and make sure you're using the right codes, especially that D 4 3 55.

Always verify umbrella plan networks like Guardian versus Guardian PPO. Update your systems. Do claim status checks every 10 days. Follow the 10, 20, 30 rule. And never enter $0. Use U, use UCR and note it for documentation only. Here are some tips that you can apply today. Print your top 20 codes and u print your top 20 codes used and double check CDT 2025 changes.

You can Google them, you can search them anywhere. You can find them in our free training@dentistrysupport.com slash free training. Train your team to recognize the top five umbrella plan networks. Start tracking claim follow ups using that 10, 20, 30 schedule. And if you're a practice that wants help with this, I mentor, coach and train dental teams all over the United States to stop missing money and start running smoother systems.

All of that is linked for you in the show notes. You don't have to guess. You just have to decide to do it better. Thank you for being here with me today, and if you found this episode of Value, go ahead and share it with your team, your bestie in Dentistry on your favorite Facebook group. We are growing stronger when we grow together.

I'll see you guys next time on the next episode of No Silver Spoons.