A dental practice needs to always focus on RCM (dental revenue cycle management) in order to stay sustainable and profitable. RCM is the chain of activities that begins when a patient makes an appointment for dental treatment and ends with the practice getting reimbursed for the same by the insurance company and the patient.
Dental revenue cycle management is like a wheel, and all the spokes play an important part in making RCM successful. The team should be aware that all steps in the cycle are important, and each step can affect the other when not completed or executed as per the process.
Dental revenue cycle management is vital for any dental practice, as cash flows depend on it, and the practice can end up losing money if any step along the way goes awry. This can result in payment denials or delays. The steps of the dental RCM and how they work are as follows:
Understanding how the steps of the RCM are interconnected needs an understanding of the definition or scope of the steps, as well as possible reasons for failure.
A patient's request for a dental appointment is the first step of the revenue cycle. The patient scheduling app of the practice needs to collect personal and insurance details of the patient. This is important for insurance verification and registration.
The insurance verification process helps the practice ascertain all the policy coverage details of the patient. The team can get a thorough understanding of all treatments and services that are covered by the plan and brief the patient accordingly. The patient is thus in a better position to understand the financial responsibility for the treatment recommended, along with the coverage and limits of the policy, before commencement of the treatment.
The practice needs to present the recommended treatment plan to the patient. The plan must include all costs associated with the recommendation. The amount covered by the insurance company must be clearly outlined.
All upfront payments that include copayments, deductibles, etc., must be explained. The patient’s financial liability for the treatment, as well as suggested payment option plans, must be discussed.
The regulatory landscape for the dental healthcare industry is dynamic, and the dental team must be completely aware of all applicable codes at the time of billing. Coding and attachments of all the relevant documents, photographs, X-rays, etc., are critical components of claim submission. The dental team needs to keep all records and notes carefully and ensure the precise usage of CDT or CPT codes. This enables the practice to get all claims processed promptly, along with timely reimbursement.
The dental team needs to post all payments received from the insurance company on the practice management software. This includes capturing dates of payments, necessary adjustments, and alignment of these payments to the respective accounts.
Aging report management is the process of following up on claims that are unpaid till payment has been received. The process involves the monitoring and management of outstanding dues. Any claims that are denied need to be appealed or reworked till a resolution is achieved.
Once payment has been received, the payment needs to be posted on the PMS. Such a step can make the insurance company accountable for processing pending claims due to the practice.
The dental team needs to bill the patient once it posts insurance payments on the software. The team needs to collect all patient dues by sending reminders using automated tools or through phone calls.
Revenues for the practice come from two sources: the patient and the insurance company. Mismanagement on the part of the dental team can lead to erratic cash flows. This can hamper the operations of the practice and lead to a lowering of patient care as well as decreased earnings.
When cash flows are affected, the practice cannot invest in resources such as people or equipment.
Given below are pointers on how the dental team can commit errors or lapses in RCM.
In this step, the dental team needs to diligently collate all details of the patient’s insurance policy, as well as their personal details. Collecting incorrect or not collecting all the required details will result in the team not being able to verify insurance accurately. This results in an incomplete or erroneous case presentation. There can also be doubts about policy coverage for the patient. Based on the treatment recommended, the team might not be able to estimate any out-of-pocket costs that the patient might have to bear. Lack of awareness of coverage provided by the insurance company might affect collections from the patient later.
The dental team must ensure that verification of the patient’s insurance policy is completed at least two days before the patient visits the clinic for treatment. Doing verification at the last minute can result in minimal time to effectively handle unexpected issues concerning policy coverage. There is a chance that the claim submitted by the team might face rejection instantly. This affects the aging report later.
The practice must ensure that they leave aside adequate time to make a detailed treatment presentation. Failure to do so could result in patients owing a larger amount to the practice than they anticipate. There might be delays in collecting dues from the patient and the insurance company. Moreover, it can negatively impact the relationships that the practice has with its patients.
The most vital aspect in billing is the submission of claims, and if the dental team has not submitted accurate claims or has not made timely submissions, there is a high probability of claim denials.
Denials or queries lead to delays in reimbursement for the practice. For most practices, more than half of the revenues come from claims sent to insurance companies. Frequent delays or rejections affect cash flows for the practice, which hamper operations. The team also needs to allocate additional time to appeal a denied claim.
When the dental team does an inaccurate posting of an insurance payment, it could cause issues with patient billing. An incorrectly posted payment will result in the team collecting the wrong amount from the patient due to an extra bill raised on the patient. This then creates a problem at the time of collection of dues from the patient and loss of goodwill.
Mere submission of claims is not enough. The dental team cannot afford the insurance aging report. Such a step leads to the piling up of unpaid insurance claims. And if the due date is gone, then these claims might never get paid. An ignored AR report is a huge challenge for the team, as it represents a large volume of money lying with the insurance company.
A lack of planned and persistent follow-up with patients for outstanding amounts due to the practice can lead to write-offs, and this affects cash flows. The practice must invest in an automated solution that eases the raising of bills and sending reminders. The team has time for other critical duties and does not focus on additional phone calls or emails to remind patients of their dues.
Enriching the patient experience is a must for any dental practice to be successful. Beyond just delivering quality care and treatment, a focus on dental revenue cycle management can ensure timely billing and collection from patients and insurance companies. Following the basic steps diligently can be highly beneficial to the practice and its patients.
