The Role of Compliance in Dental Billing: Why It Cannot Be Ignored

Compliance covers all industries, and the dental healthcare industry is no exception. A streamlined and well-governed compliance program can greatly benefit any dental practice by preventing any unwarranted problems with the regulatory bodies.

A dental practice that makes claim submissions to Medicare or Medicaid for payment cannot think of operating an ineffective compliance program. The practice must have a comprehensive plan to undertake regular internal audits of all claims that are submitted for reimbursement. The audits must ensure that services rendered are thoroughly documented, deemed necessary, and billed accurately with the right codes.

It is not difficult for any practice to design and implement an effective dental billing compliance program. It does not cost much to administer such a program. In fact, it can help to reduce costs by lowering error rates. Proactive and accurate dental claims submissions with consistent follow-up are not merely administrative tasks but are the hallmark of a practice that stays compliant.

The Necessity for Compliance in Dental Healthcare

There are many elements to manage when running a dental practice. There needs to be priority for other areas, and not just treatment and services. There are challenges to be met when it comes to billing and coding. The regulatory landscape is dynamic and changing. This means that the dental team must stay alert and be equipped to help the practice stay compliant.

The practice must embrace these challenges and realize that there are severe outcomes that must be faced if it fails to stay compliant in billing and coding.
A carefully designed and ingrained culture of compliance can help to lay the foundation of the legal and ethical behaviour of the practice. It brings along various other benefits too.

Ensuring HIPAA Compliance

Dental billing involves claims submissions to multiple insurance organizations. The practice needs to get compensated for the services that are offered to patients. The process, however, is not just the preparation of bills and submissions. It encompasses the careful handling of ePHI or PHI (electronic Protected Health Information) records during all the stages of claim submission.

HIPAA ensures that all ePHI or PHI are handled and administered with the utmost regard for security throughout all stages of claim submission.

Key objectives of HIPAA

The main task of HIPAA Regulations is to uphold and safeguard the integrity of electronic Protected Health Information based on key concerns:

• A privacy rule that sets privacy standards for ePHI or PHI.
• A security rule that promotes standardization of ePHI or PHI management and handling.
• A breach notification rule that mandates all dental practices and the covered entities get immediately alerted when they are affected and health information is compromised.

Billing and Coding Compliance

The main purpose of being compliant for a dental practice in billing and coding is to carefully monitor all the pertinent clinical documentation and the necessity for the various procedures and services provided to any patient at the dental practice. The dental team must make sure that state or federal laws that govern a dental practice are being adhered to. The team also needs to follow regulatory guidelines laid out for billing and coding.

A dental practice can face a financial setback and reputational damage due to errors in billing and coding. Allegations of fraud, steep legal fees, and penalties can be detrimental to a dental practice. Some errors can be marginal, but a lack of understanding of guidelines or laws cannot be termed as an excuse for a violation, if any.

Steps that A Practice Can Follow to Stay Compliant

Accuracy in billing and coding is a vital aspect for running a successful practice. As the complexity of dental coding and billing keeps increasing, it makes great sense for a practice to seek support from a reputable dental billing company to handle all billing and coding requirements. They can provide optimal solutions to manage challenges faced by dental practices and help them stay compliant. Some steps that a practice can adopt are as follows.

• Streamlined processes and workflows: A smooth and efficient billing process promotes a streamlined workflow. It lowers the administrative burden on the dental team and results in a lower number of possible errors. It results in accurate coding and timely claim submissions.
• Improved cash flows: Timely submissions of claims and consistent follow-ups for pending payments help maximize revenue collection and profitability.
• Staying compliant: Mastering the evolving maze of dental billing and coding is not an easy task. The practice needs to regularly equip the team with comprehensive knowledge and expertise in dental billing solutions to help safeguard it from any compliance issues. This can lower the chance of penalties and a dent in the reputation of the practice.
• A richer patient experience: By staying compliant, a practice can help create a richer patient experience. Negligible billing errors and prompt submission of claims can help the practice to provide precise billing information to patients while also informing them of their pending dues. This results in greater satisfaction and affinity for the practice and helps to maintain cordial patient relationships.

Compliance Readiness Checklist

• Charting and documentation: The team should ensure that clinical notes outline and record the diagnosis, treatment recommendations, and suggested procedures that have been performed. The progress notes need to be signed by the dental practitioner with the date. All images, X-rays, etc, must be linked to patient files. Signed consent forms must be made available for surgical procedures. The necessity for procedures must also be documented.
• Billing and coding: All CDT codes incorporated in billing need to match the procedures outlined in the clinical notes. If modifiers are used, they need to be appropriately used when necessary. All claims must be thoroughly reviewed before submission for accuracy. COB (coordination of benefits needs to be decided correctly, along with primary and secondary explanations of benefits.
• Periodic training: The dental team must be frequently trained on billing, coding, and documentation, as this helps the practice to stay compliant. The practice can designate a particular employee to review for compliance readiness.
• Retention of records: Patient information and records need to be securely stored and made accessible when needed. All HIPAA guidelines must be followed. Records need to be preserved as per the respective state or insurance regulations. The practice must ensure that backup systems for digital records are always on.

Conclusion

An effective and robust dental compliance program enables the practice to avoid potential issues with regulatory bodies. A dental practice that must make claim submissions to insurance companies, Medicaid, or Medicare cannot have a lackadaisical approach towards compliance. A meticulous plan to stay compliant must be developed and always followed.