Billing extraordinaire Sarah O’Brien is on the podcast! Sarah and Kiera are talking all things documentation + getting your claims paid faster. Included topics are …
Why documentation is important
How it relates to billing
What SOAP notes are
Why better notes = better patient experience
How to get the right information to insurance companies
Check out Sarah’s documentation reference sheet!
Connect with Sarah: [email protected]
Learn more about Evolution Dental Billing
Listen to episode 296, Unveiling the Art of Negotiating Fee Schedules
Listen to episode 291, 2020 — Close Your Billing Out Strong
Subscribe to The Dental A-Team podcast
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0:00:05.6 Kiera Dent: Hey everyone, welcome to the Dental A Team Podcast. I'm your host, Kiera Dent. And I had this crazy idea that maybe I could combine a doctor and a team member's perspective, because let's face it, dentistry can be a challenging profession with those two perspectives. I've been a dental assistant, treatment coordinator, scheduler, biller, office manager, regional manager, practice owner, and I have a team of traveling consultants for we have traveled to over 165 different offices coaching teams. Yep, we don't just understand you, we are you. Our mission is to positively impact the world of dental, and I believe that this podcast is the greatest way I can help elevate teams, grow VIP experiences, reduce stress and create A teams. Welcome to the Dental A Team podcast.
0:00:51.7 KD: Hello, Dental A Team listeners, this is Kiera, and you guys, I am so excited to bring back one of my dear friends, somebody who I use all the time. She is my go-to biller girl. She is somebody who has her own billing company, and right now, I know outsourcing and figuring out how to maximize our billing with all the changes coming through is totally something you guys are needing. So I'm super jazzed to welcome back, Sarah O'Brien, she is the owner and founder of Evolution Dental Billing. Sarah, welcome to the show.
0:01:19.0 Sarah O'Brien: Hey, Kiera, thank you so much. I'm so happy to be here.
0:01:22.6 KD: Absolutely, it's been a hot minute. I mean, we do live in the same state, but [chuckle] you're in Vegas, kind of the cooler part of Nevada and I... Like, cooler as in more hip, more [chuckle] up and coming, not necessarily temperature. [chuckle] I mean the temperature cool.
0:01:36.5 SO: Yeah, definitely. [chuckle]
0:01:37.5 KD: And I'm over here in Reno, I feel like... It feels so far away even though we're in the same state, but surely, I appreciate you, you're always the girl I call. Guys like, I'm not kidding, when I'm in an office and people ask me like, Kiera, what about this for billing? I'm like, hang on, I'll get back to you. I'm like, Sarah, I don't know. [laughter] It happens often.
0:01:55.8 SO: Yeah. I love it when you call, I'm so happy to answer questions and help people, just kind of understand. It's such a mystery sometimes what is going on, so if I can offer any clarification, I'm super glad to.
0:02:07.1 KD: Well, and also if you guys haven't picked up on the fact of Sarah, Sarah is also the nicest biller I think I've ever met in my entire life. Sometimes billers are not as nice as you, Sarah. So the fact that you love it, you're like GSD girl, you get it done, you know your stuff, you bill for tons of offices. So kinda tell us in a nutshell like, what does Evolution Dental Billing do? What kind of services do you do? Before we dive into, guys, we're gonna dive into documentation and how to get your claims paid faster. So, Sarah, what exactly does Evolution Billing do?
0:02:40.1 SO: So, Evolution Dental Billing is a remote dental claim service. We basically try to take the entire claim from the office off of your desk into our lap and handle it from start to finish. So you see the patient, you post the treatment, you can either back your claims or let them hang. We'll review for common errors, submit those to the insurance companies, then after they've processed and paid, we'll post your payments, whether it's check or EFT, we'll allocate those 100% accurately. We're gonna document every bit of the information from the claim so that you know what it said without having to look. And then if there's anything that isn't paid, we're gonna chase those down every 30 days, 30, 60, 90 days, follow up with the insurance company, figure out what they need and what they're doing, and try and get those claims to process and pay. So it's 100% dental claims, 100% remote, and I feel like we've had some really good success taking that piece of the pie from the office teams and doing it remotely, and offering a really good service for them.
0:03:47.4 KD: I would agree, and I refer you to several of our practices. There's some other companies out there. The reason I refer you, Sarah, is because 1, I know you personally 2, you do a great job, and 3, I know the human on the other side. So, that's always a perk for me. And she does a great job, guys. So if you're in need of that, something else that you didn't mention that I know you've done for a lot of our clients is, if you're in a transition, like let's say you've lost your biller, you can outsource to Sarah for a while, and then when you have a new biller that starts, Sarah actually is a rock star and trains that new hire for you, so... Sarah, you've trained a ton of our officers, you've helped them learn how to do it, transition them to be able to do it in-house, and I will say that, that I think is something that not a lot of people are willing to do. So guys, if you are needing help, Sarah, how can they actually get in touch with you? I hate when it's always at the end, of course, we'll do it at the end too, but if people want, they're like, Oh my gosh, I need you to, yeah like five days ago. How can they get in touch with you?
0:04:45.1 SO: Just email me [email protected], or you can call my cell 602-318-9396.
0:04:52.8 KD: I'm not kidding, I text her, 2:00, 3:00, 4:00 in the morning. And as soon as she wakes up, she responds, like East Coast, West Coast, wherever I'm at, Sarah is there. But, guys, I just am excited 'cause Sarah, one, is super proactive. So Sarah, let's dive into this, you have a really cool document which we will attach to the show notes, and you have a documentation reference sheet, and I love here on your note, you said, if it isn't documented, it didn't happen, which I agree. So kind of walk us through why documentation and how it relates to billing and getting paid faster and all the claims like let's just kinda dive right into this documentation.
0:05:25.5 SO: Let's. Okay, so documentation is multiple levels of important, right? There's your basic information, we need to kinda know who we saw and what we did, kind of basic, but it's much deeper than that. Your documentation of your chart notes is a legal clinical document of the care that is being provided to your patients. It is not just, patient came in, we put filling, bonded with this material. It's actually a legal representation of the quality of the care that we're providing to our patients, and if anybody needs that, we want it to be on... Not on par, above par. We need it to be something that we can present to people in the future, if they ever have need of it, that's gonna showcase and outline from start to finish the who, what, when, where, why, and hows. So it's super important. It's kind of one of the things that I preach about the most, to be totally honest. It's very, very common when I look at an offices' chart notes that it is a step-by-step of the procedure, patient presents for number 30 composite, use this anesthetic with topical, place etch bond fill material, and certain names here, which is all super important, but there's way more to it than that, right?
0:06:47.6 SO: It's supposed to be above and beyond the step-by-step for their procedure, which is why I kinda came up with the outline for the reference sheet using the SOAP note protocol is kind of the ideal method for making sure that all of that important stuff is documented. For those of you who don't know, SOAP is an acronym, it's subjective, objective, actual, and plan. So it's an easy way to remember what you need to write, when, and why.
0:07:18.0 SO: Subjective information is, what would the patient say when they come in, what did they think they're here for? So you bring Mrs. Smith back, and Mrs. Smith says, Oh I'm here for my filling. Yay. Okay, great. Patient presents for filling. Here we go. Is she having any problems? Is there any other information that the patient relays while we're kind of getting them seated and prepared for the doctor to come in? What are you talking about? What you... Are we talking about the procedure? Are we talking about her life? Whatever it is, make note of it. It's a thing.
0:07:53.8 SO: The next one is O for objective, and that would be, what is observable? What are the existing conditions that are present in the patient's mouth that require treatment to be performed? And what methods were used to determine these? So PA of tooth number three, taken whenever, reveals decay of the mesial surface, also failed a previous occlusal composite, whatever it is, document what the patient comes into the operatory with, so that we know their condition at that moment, if the... Say, the treatment plan was three months ago, and since then the tooth has fractured, or if there's a visible craze line, which is a superficial line in the enamel, whatever it is, we wanna make sure that we're documenting that information clearly because there's no way to go back in time and remember it later. You're seeing, what, 10, 12 patients a day, more sometimes, and it's really hard to pin down and backtrack to know that stuff later on, so make it part of your routine to make sure you're documenting all of the clinical observable conditions prior to beginning treatment. Now that you're...
0:09:15.3 KD: And I think this is a good spot, Sarah, I wanted to interject on that, of like this is a good spot for... If it's a crown that we say that we have the intra-oral photos and the x-rays taken before we're about to do treatment, like that's how we determine these findings of PA because, Oh, well, dang, we don't have that PA or that intra-oral photo. Heaven help us all, we're not getting that dang claim paid because we didn't have it.
0:09:39.9 SO: Absolutely.
0:09:40.5 KD: So those types of prompts, you can totally put these in in your notes for prompts, but I agree with, Sarah. You've got to have this in there, so people then can... We know whether they're... From what they're saying and also what the objective is. Guys, if you don't know, so SOAP does come from the medical field, and I think dentistry could ramp up just as [0:10:00.9] ____ coach on our professionalism and our consistency of our notes. So I'm excited, Sarah, what is the A for?
0:10:07.4 SO: A is for actual, that's when you're gonna list the step-by-steps of the procedure from start to finish, place topical, what type of anesthetic, how many carbs, what brands and amounts, and all of those bits and pieces that actually produce the completed treatment. That's where you're gonna note the actual start to finish of the appointment, those are your actual.
0:10:30.7 KD: And then your P is the plan, which I'm always obsessed with of like, what's the patient's next step?
0:10:36.0 SO: Exactly.
0:10:36.3 KD: Tell us what they're coming back for, because I can't tell you how many times as a front office trying to schedule this patient back and I'm like, I don't even know what the heck I need to schedule them for. So this piece is super helpful, it can be your next visit, P. It helps with SOAP, so you remember the SOAP note, but I think it's a really, really, really good way to go through it and it helps because then also if everybody's writing their notes the exact same way, when your billers come through and need to extract the information that they need to see, they know exactly where to look within the note rather than having to read that entire clinical note that they don't even need 90% of it. They need that 5% to 10% to pull out of there to send on the claim. So insurance knows why we're doing this and we've got the required documentation for it.
0:11:17.5 SO: Exactly. Initially, suppose you've seen the patient and outlined treatment plan, quadrant dentistry, quadrant two is supposed to be upper left, what if the patient has a toothache in a different area? You wanna note then that the next part of the plan has changed, so it's important for multiple reasons. Billers wanna know it, obviously, and also your treatment coordinators are probably kind of curious to know what's next. So it's really... It's helpful. It covers all the bases and it presents it in an easy to remember form, so the SOAP notes are awesome. It really, really helps everybody kind of make sure that they're documenting all of that important information and then not anyone in the future, because your future self will thank you for making note of it now. So SOAP note's way to go.
0:12:08.0 KD: How many of you would just love to DIY and get the secrets of people who have been there, done that, on your own time? Because I know for me, I love to learn from the best of the best, the people who have been there, done that, and can give me the shortcuts. That's why we have created our Dental A Team Virtual Academy where it's on-demand courses for you at your fingertips, where you literally can learn the secrets from all of my experience, all of Tiffanie's experience, Brittany, Dana, our entire team's experience at your fingertips. So stop taking the hard route, guys, there's a shortcut sitting there waiting for you, and it's also CE. Head on over to thedentalateam.com, and click on our Virtual Academy. Be sure to use coupon code "Podcast" and get started on that DIY and become the practice of your dreams.
0:12:53.2 KD: Yeah, for sure. And I think something on there that is important is a lot of offices might not be outsourcing billing, but just imagine and get your practice to the level of... Pretend that Sarah is going to bill your practices' claims, could she, without ever speaking to somebody in your practice, go into your notes, figure out why this patient was here, what the treatment was, why this crown was needed, or why this filling was needed, to be able to send the claim without you ever speaking to her? That is like the level of sophistication your practice should be operating at whether you choose to outsource billing or not, because if you have that, your practice, if you have an internal biller or an external biller can get those claims paid and your patients are going to be taken care of because we've got everything documented. True of false, Sarah?
0:13:45.2 SO: Right. True. 100%. Another thing I like to kind of threaten practices sort of thing, is imagine an insurance audit, imagine an insurance auditor coming to your practice and trying to decide whether the standard that you're keeping is where they require it to be. So if some outside person were to come into your practice and pull a chart and say, the reason a crown was done according to the assistant was discoloration. Now, that could be a reason for a crown, absolutely, but it would probably be considered aesthetic or cosmetic rather than a clinical condition. So making sure that all of that information... Aesthetics is important, of course, and you wanna document that. But go deeper than that. What caused the discoloration? What was the condition of the tooth that deteriorated to discolor? You know what I mean?
0:14:40.2 KD: For sure. Which I think is... I mean, that's not a... It's not a threat, it's a reality because that's ultimately why we got to document all these. So, Sarah, I think on your reference sheet, something that people don't realize is that within this documentation there are certain things that you need to have. Sarah, on the sheet that you have, which you guys should totally go to the website, thedentalateam.com, click on the podcast link in today's podcast, this is where this form will be linked for you, but Sarah has it broken down of like in diagnostic, in endo, in perio, in pros, in ortho, in financial, what things need to actually be included in these notes and the type of things you need?
0:15:17.9 KD: So for example, like tooth-by-tooth assessment, risk assessment under diagnostic and evaluation, diagnosis and prognosis, diagnostic quality, radiographs and photos, all of that needs to be in there. And Sarah, why are those things... Like you have this broken down into like the most beautiful little checklist, which I'm obsessed with checklists, 'cause I think teams can do it, and also looking at this, I'm like, Perfect. This becomes your note templates of what things need to be in there, and also you can link this to certain codes, so when they close out this type of diagnosis and notes can actually be auto'd into there of what's going on. So why are these things so important in the documentation? I get it, if I didn't document it, I didn't do it. But how does this help me get paid or have a better patient experience?
0:15:58.6 SO: When we submit your claims, there are certain required bits of information that have to be submitted along with the code. So for example, with a root canal, we have to make note of the condition or the diagnosis of that particular tooth. Is it irreversible pulpitis? Was there a periapical abscess? Did the decay go all the way into the nerve and the root canal was required? What was the reason for that root canal? In addition to that, they need to know how many canals and the lengths of those canals. It is one of the mysteries of dental insurance processing that who knows why they need that information. What are they gonna do with the length of the mesial buccal root? I don't know, but they want it. [chuckle]
0:16:41.8 KD: They don't actually care. I feel like it's like taxes, they just wanna create as many loopholes and hoops for you to jump through for them not to have to pay. I actually don't think they care.
0:16:50.3 SO: Exactly.
0:16:51.3 KD: They just wanna make sure you check their boxes, otherwise we will not pay you.
0:16:54.9 SO: Yeah, exactly. Those are the things that we're trying to avoid is to avoid the delays and the additional information request and eventual denials, so that those claims can process and pay in a few days rather than a few weeks or months. So I broke it down by kind of procedure category, endo, diagnosis, canals and lengths. For perio, you wanna know the perio class. If someone's coming in for SRPs, are they class 1, 2, 3, or 4? What are the bone levels? Is there horizontal or vertical bone loss? Is there recession present? Is there blood on probing or separation? And what about the calculus supra, sub gingival? Is it creating all an entire bridge connecting all of their lower teeth? Whatever it is, document clearly, so that there's fewer reasons to delay.
0:17:44.3 SO: For prosthodontics, whether it's removable or fixed, we have to know whether it's an initial or a replacement. If it's a replacement, please, please, please note about how long ago it was done. If the patient's like, Oh, I don't know, a few years ago. Okay, well, was that a few years ago with this dentist? Try and coach them to give you more information on that because your dental plans consistently have a minimum of five years before they're gonna replace the crown, whether they're the ones that paid the initial or not.
0:18:14.5 SO: So if we just kind of flippantly write patient says a few years old, the insurance is not gonna accept that claim, they're gonna kick it back for more information and we're gonna have to end up calling the patient again anyway, so you might as well document that. I think in the initial kind of the comprehensive exam as you're documenting the tooth by tooth, what's existing conditions, hey, you've got a crown on this upper right side, do you know about how long ago that was done? Lead them to that while they're in your chair and save yourself all of that hassle later on trying to get it from them. And that goes for partials and dentures as well. If they've got a partial in their mouth, How long have you had this thing? And they're like, Oh gosh, since the 1970s. Okay, great. Well, we'll make note of that.
0:18:58.3 SO: That way, when the dentist decide that it is not replaced... Or not repairable and it has to be replaced, we've already made note that it's 50 years old and there's... It's time for a new one. Along with that goes your missing teeth. When was this tooth extracted? When you were a teenager, was it when... When you lived in Liverpool, whatever it is, make note of when those teeth are removed because a lot of plans have missing tooth clauses, which says that they will not cover a procedure for a tooth that was removed prior to the plan becoming effective, which if a tooth is congenitally missing, which is a super common thing that we see, then we wanna make sure that we're putting that in our narrative because that might be a way around the missing tooth clause. It was always missing. It's never been there.
0:19:49.9 SO: So again, one other thing, the buildups. Buildups are the biggest fight we have in dental billing. It is, it's like I see a buildup on a claim and I'm like, I pulled my sleeves up, I tie gloves on, I put my hair back, I'm like ready for the fight. So a buildup, we need to know what percent of this tooth structure was missing, after the decay and the previous restoration, after you got down to solid dentin or whatever, about how much tooth did you take away? Was it 50%? Was it 80%? Make sure that you're noting that information because we need it for your claim, and then take a picture of the tooth after all of that stuff is removed, so that we can send that as well.
0:20:33.2 SO: Next is your ortho. What's the ortho class? Is there a cross-bite, overbite, under-jet? Whatever it is. Is it gonna be regular braces, brackets, is it gonna be Invisalign? How many months or weeks are we expecting your treatment to be? That has to be submitted with ortho claims, and if you have a bunch that are outstanding, it's probably because they don't document how long the treatment is expected to be. And then we also need to know when the band bond or deliver date is. If the case hasn't delivered yet, if you make note of when it's expected to, some insurances will process and pay, some of them will kick it back and say, Please let us know when you actually give this to the patient, and then we'll resubmit it then.
0:21:16.8 SO: Last but not least, the other notes that need to be included in your patients' chart are financial notes. There is much more to dentistry than putting your hands in their mouth and fixing a broken tooth. There's all of the discussions and arrangements that we make with the patient leading up to that situation. So financial arrangements, if there's a out-of-pocket cost for this, are they paying at this appointment? Have we agreed to let them pay over time? Are we breaking up the total cost of their care into payments so that each time they come, they pay kind of a matching amount? So $1000 out of pocket, $200 per visit, whatever it is, make those notes so that if you're not in the office that day, then your teammate will be able to pull it up, know where to look and know what to collect.
0:22:02.0 KD: And I'm curious on that, Sarah, because I've heard mixed reviews of, should those financials be in clinical notes or should they be in the patient chart, or should they be in the like an Open Dental in the Comlog? What's your reasoning for putting them in clinical? 'Cause I do know some offices will have clinical signed off by the clinician, and then they go back and have a treatment coordinator add it. What's kind of the reason behind putting in the clinical note, or are you just saying add it somewhere within the note for that patient, so that way it's all documented?
0:22:33.8 SO: Correct. It really depends on the software where it ends up, as long as it's somewhere and everyone knows where, then that is 100% sufficient. If your clinical software requires kind of like all the notes to be in one place, then you can usually change financial notes to be a different color so that they'll stand up, like green, for example, 'cause it's money related, I don't know.
0:22:58.1 KD: Yeah, I like it.
0:23:01.8 SO: Kind of just get used to having the documentation in a same spot every time, and then that will help anyone. If your front office is out sick and your back office is checking out, are they gonna know where those financial notes are located? So it's another reason that I think kind of putting them all all together is a good thing.
0:23:19.0 KD: Perfect, which I love. And guys, the thing about this is Sarah said to get it paid within a week rather than a month to two months, so we're not chasing money. To me, that's just where we're at of like, Why not do this, why not look for ways to simplify it? And I think one of the easiest ways to do this is actually like, let's go look at our note templates, let's see our note templates set up for this. With the checklist that, you guys, Sarah's so graciously giving you guys, download that, put it in your note templates, and let's ensure that it's actually going to be what you're trying to have it become. And then check to see, can you get your claims paid?
0:23:54.5 KD: There is a back side of if claims are being denied, you need to update those notes, or for certain insurances is to what we need to add, like Sarah learned about buildups not because she works for an insurance company but because she's literally seen hundreds and hundreds of buildups being denied, and she's figured out how to work around that. So I think create this, guys. This is something you can do that's very easy, have a team meeting, get your notes put into play, make sure the information's there, and then have your billing team report back of what information's needed to be added and make it very simple.
0:24:29.0 KD: Guys, this is where you can make your life very easy by spending one to two hours of time to get all your notes put together and everybody document in the same way to save you hours of time chasing money, hours of dollars spent chasing money when you could just spend two hours of a meeting. That's kind of my thought process there. Do you have any better ways for offices to implement this and make it really easy for them?
0:24:51.0 SO: No, I love the templates, I think they're super helpful. Kind of have a team meeting and kind of discuss the method or the madness, so here's what we're doing, here's what we need to know, here's why we need to know it. Make sure everyone understands the reasons and the ideal outcome and then go from there. One thing that I will say is, in addition to having the information documented, make sure it's accurate. Make sure you're using the correct tooth number for what's actually being worked on. Make sure you're using the correct surfaces that are actually being completed. In addition to having the bare bones, make sure the meat is there as well.
0:25:31.0 KD: Yes. Amen to that. Sarah, that was super, super helpful. I appreciate it a ton. Guys, like I said, head on over to thedentalateam.com, click on the podcast tab, select this podcast, and that's where this document is gonna be attached. But if you guys are looking for help, you want Sarah to help train your team or to help you guys with outsourcing billing, again, Sarah, how can they connect with you? Because I think you're such an amazing 1, person 2, you're a great resource in billing, and 3, you just crush it on billing. I've had a ton of offices we've referred to you, just say how much they value and appreciate you. Sarah, how can they connect to you if they are like, we need billing help five days ago, again, how can they connect with you?
0:26:07.8 SO: Give me a call, 602-318-9396. Or check out the website, evolutiondentalbilling.com. Or email me, [email protected]
0:26:20.9 KD: Awesome. Well, Sarah, I appreciate you a ton. Guys, check her out. Sarah, thanks for just being one of my favorite people of all time, I use her, I refer her. She's the best. Sarah, thanks for sharing this information. I think it's really important for people to document and to understand why we need to document.
0:26:35.0 SO: Thank you, Kiera. I hope it helps.
0:26:36.7 KD: Absolutely. Alright, guys, as always, thank you for listening, and I'll catch you next time on The Dental A Team podcast.
0:26:45.1 KD: And that wraps it up for another episode of The Dental A Team podcast. Thank you so much for listening and we'll talk to you next time.
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