The Most Common Challenges: Verification and Breakdown Challenge

I answer questions every day from dentists and team members needing help on anything from insurance to practice management. Most tend to have the same basic questions, so in this series I hope to answer the most common questions that tend to plague dental offices.

Verification and Breakdown Challenge

Getting information from an insurance company can be tedious, difficult, time-consuming, and just an overall pain in the rear. Because of this, most offices tend to try to bypass or skip this step, which leads to many other issues: poor collections, inaccurate estimates, unhappy patients, negative atmosphere, and more.

One of the most common terms in computers is “garbage in = garbage out”, which can apply to dentistry so well.

If you don’t have current, accurate data from insurance, your treatment estimates may be off, and everything else falls like a line of dominos.

Previous articles discussed improving collections percentage to above 99% and eliminating surprise bills for patients. These are crucial for running a profitable, growing office with happy patients and doctors. To achieve this goal requires putting more effort into the verification and breakdown process so that you have reliable information for creating treatment plans and everything else that follows.

Verification is quick and easy and should be done literally for every patient, every visit. Unlike medical plans, dental plans do not cut off at the end of the month. Dental policies end on the day the patient ends or changes their employment, which means it could be any day of the month. One of the most frustrating problems working with insurance is when they demand a refund months after payment because the patient’s policy was no longer active on the day of treatment. (More about how and why this happens here: https://dentalinsuranceguy.com/resources/articles/how-to-handle-dental-insurance-refund-demands/ )

Some insurers include a clause in their contract that they will not ask for a refund if you verified the patient within 24-48 hours of the date of service. This protects the office and even the patient to some extent, but only if you verify before every visit.

Breakdown of Benefits is the process of uncovering all the nuanced details about the patient’s insurance policy so you know upfront what insurance will and will not reimburse for. Only by having a very detailed breakdown, often called an IVF (insurance verification form), can one provide the patient with a treatment plan and estimate that will be accurate.

If offices invested as much time and effort into compiling good verification and breakdowns as they do in collections, they wouldn’t need nearly as much effort to collect. I once ran a $2.8M collections office with only a single page of Accounts Receivable balances at any given time. This was possible because of great benefits information and using it to create nearly perfect estimates that mostly resulted in patient credits from any inaccuracies.

So, why don’t more offices spend the necessary time and effort on verification and breakdowns?

Some are so busy chasing down past balances that they have difficulty catching up. Verification and breakdowns can be a mind-numbing data-gathering and entry process. Or sometimes there’s just a lack of understanding about its importance, how to get the information, or what a good IVF looks like. And, finally, there’s the lack of overall time. A person verifying insurance may spend 30-60 minutes on the phone, mostly on hold, just to get more information from the insurer.  This process, when done correctly in an average office, can take a majority of a team member’s time during the day. In our office, it was taking a full-time employee to manage. If you have the team members to do this, great!

If not, there are alternatives. Artificial intelligence applications for dentistry have improved to the point of being able to get this data far faster and with fewer errors than a human. We installed an AI to manage our verification and breakdowns, and the team absolutely loved it. Initially it provided my team with a lot more time to handle other tasks. And when we lost someone to relocation, we were able to maintain that reduced staffing level without hiring a replacement.

Having done significant research in this space, just be aware that not all AI are equal. Many gather data from only one source, which leads to inaccuracies and incomplete data. The AI we found provides data from three different sources, which have become just as good at gathering accurate data as our full-time team members used to. 

Whether you gather data through a team member or AI, the key is ensuring it’s the most accurate data available and that you are getting it consistently. Avoid the “garbage in / garbage out” challenge.

Once you have good data, you need to know how to understand and apply it to create accurate treatment plans. The next article will focus on how to interpret insurance data and use it effectively.

In the meantime, happy verifying!

If you want to check out the AI that I found, use, and have helped to improve, check out DIVA here: https://dentalinsuranceai.com/