Why Dental Business Verification Is Essential

For dental billing companies, verification is the crucial process of ensuring that a patient’s dental insurance is active and their specific plan covers the services they’re about to receive. It’s a key step for both the billing company and the dental practice to prevent claim denials and ensure timely payment.

Verifying a patient’s insurance information before their appointment is the cornerstone of a successful dental billing operation. Without it, the dental practice risks providing a service that won’t be covered, leading to unexpected bills for the patient and lost revenue for the practice.

• Maximizes Revenue: Verification prevents claim rejections and denials by confirming the patient’s eligibility, benefits, and coverage limitations upfront. This ensures that the submitted claims are “clean” and get paid the first time.
• Improves Patient Experience: Nobody likes surprise bills. By verifying coverage beforehand, the dental practice can give patients an accurate estimate of their out-of-pocket costs, leading to greater transparency and patient satisfaction.
• Reduces Administrative Burden: For the dental practice, outsourcing this task to a billing company frees up the front office staff to focus on patient care and in-person communication rather than spending hours on the phone with insurance companies.
• Ensures Compliance: The verification process helps the billing company and the practice adhere to regulations like HIPAA by handling sensitive patient data securely.

The Verification Process

The verification process for a dental billing company is meticulous and often involves several key steps:

1. Patient Information Collection: The process starts when the patient schedules an appointment. The billing company gathers essential details like the patient’s name, date of birth, insurance carrier, policy number, and group number.
2. Eligibility Check: The biller then contacts the insurance company, often through an online portal or a phone call, to verify that the patient’s insurance is active and effective on the date of service.
3. Benefit Breakdown: This is the most detailed part of the process. The biller gets a full breakdown of the patient’s plan, including:
   • Deductibles: The amount the patient must pay before the insurance begins to cover costs.
   • Annual Maximums: The total dollar amount the insurance will pay for dental care in a plan year.
   • Coverage Percentages: The percentage the insurance company will cover for different types of procedures (e.g., 100% for preventative care, 80% for basic, 50% for major).
   • Frequencies and Limitations: This includes details on how often a service is covered (e.g., two cleanings per year, one set of X-rays every two years).
   • Waiting Periods: If the patient is on a new plan, some services may not be covered until a specific period has passed.
4. Prior Authorization: For certain costly or complex procedures, such as orthodontics or extensive restorative work, the billing company may need to obtain prior authorization from the insurance provider before the service can be performed. This is an additional layer of verification that guarantees payment.
5. Documentation and Communication: All verified information is meticulously documented and shared with the dental practice. This ensures the practice’s staff can accurately quote the patient’s financial responsibility and helps in creating a “clean” claim after the treatment is completed.

Credentialing and Business Licensing

While verification focuses on the patient’s insurance, dental billing companies also need to undergo their own business verification, which often includes credentialing. This process validates the billing company’s qualifications, expertise, and legal standing.

• Business Registration and Licensing: A legitimate dental billing company must be registered as a legal entity and have the necessary business licenses to operate in their state or country.
• Certifications and Training: Many companies will have their staff members credentialed through recognized bodies like the American Association of Professional Coders (AAPC), which demonstrates expertise in dental coding and billing.
• HIPAA Compliance: Given the sensitive nature of patient health information, a reputable billing company must be able to prove that it is fully compliant with all privacy regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) in the U.S.