12 Rules for the Insurance Game

Learn how to efficiently work with insurance to help your practice get paid. 

Updated 6/30/20

First, take a deep breath and realize insurance is a game with the cards stacked in favor of the insurance company. They get to make the rules, change the rules, and they like to keep their money. Do not get emotional. It is a game. Learn as many of the rules as you can so you can play the game better. Here are a few.

  1. Send all insurance electronically daily. Batch the claims, and be sure all clinical staff check their day sheets for procedure correctness before sending claims. Check the claims submission report and fix any rejections or problems.

  2. Take good x-rays. Show the apex of the root for prosthodontic procedures. Show the crestal bone (upper AND lower) for perio. Attach these digitally.

  3. Over prove for perio and prosthodontic procedures. Send everything you can with the claim. For crowns, send a pre-op x-ray and an intraoral camera picture of that tooth. For perio, send an FMX with vertical bitewings–the insurance carrier has to see bone loss and a full perio chart with recession and bleeding points charted, not just pocket depth. For implants, partials, and dentures, send a panoramic x-ray. Send a narrative if it is not abundantly obvious that the service is needed.

  4. Get the clinical team involved. Have them complete a procedural form for every prosthodontic procedure.

  5. Ask patients to update their insurance information annually. Employers are changing their carriers at a rapid rate. Do not rely on the patient to tell you that their insurance has changed. Create an update form and use it consistently.

  6. Get insurance data before the new patient comes in. Verify coverage, benefits available, what the patients has already had done, and intervals for basics like panoramic x-rays, bitewings, fluoride, etc. Use the eCentral eligibility feature or look this up online, if possible. If not, call the carrier or use an insurance data service. Enter the proper information into the specific group plan in the Family File. When a new patient comes with a new insurance group, have a system that everyone follows so you do not duplicate insurance groups in Dentrix.

  7. Enter all PPO fee schedules into Dentrix. Attach the fee schedule to the patient’s insurance group in the Dental Insurance Plan Information dialog box. This way you have an accurate treatment plan print out and fee co-pay estimation.

  8. Call or check online about the status of claims not paid in 30 days. Ask the carrier for payment within 10 days. Make a note in the Insurance Claim Status dialog box within the claim that indicates your intervention to check the claim status. Be sure the patient is sent a statement when statements go out, and add a billing statement note that explains that you have followed up on the claim.

  9. Call or check online about the status of claims not paid in 60 days. Ask the carrier for payment within 10 days. Make a note in the Insurance Claim Status dialog box within the claim that indicates your SECOND intervention to follow up on the claim. Be sure the patient is sent a statement when statements go out, and add a billing statement note that explains that you have followed up on the claim.

  10. Call or check online about the status of claims not paid in 90 days. Ask the carrier for payment within 10 days. Make a note in the Insurance Claim Status dialog box within the claim that indicates your THIRD AND LAST intervention to follow up on their claim. Be sure the patient is sent a statement when statements go out, and add a billing statement note that explains that you have followed up on the claim.

  11. Run your Insurance Aging Report and print status notes on the report. For all claims where you have taken intervention action three times and that are over 90 days old, follow this protocol: Print and then close all claims at 90 days that have not been paid. Then, send a copy of the claim to the patient along with a cover letter stating that you have attempted three times to obtain payment from their carrier. Next, send a statement to the patient that indicates that the balance is due within 10 days.

  12. Avoid unnecessary pre-treatment estimates at all costs. Pre-treatment estimates often become unscheduled treatment. Instead, use an online service to look up benefits, and use good common sense. If the tooth has a large amalgam with a broken cusp, have your team take an intra-oral picture to attach to the claim with the x-ray and narrative. If both teeth on either side of a bridge site need crowns and the tooth fits the parameters of the policy, don’t pre-estimate. If, on the other hand, the tooth was lost before the policy, not within, then you need a pre-estimate to see whether the bridge is covered. Most plans don’t like to pay for bridges if the teeth on either side are good and the tooth was removed outside of the policy dates.

A couple more: Go to an insurance update course annually. Use Dr. Charles Blair’s Coding with Confidence as your rule book of the game. Take his newsletter: www.drcharlesblair.com.

Make your insurance system and protocols consistent. Take time each day to do these steps. Patients are relying on their insurance more than ever. Know how to efficiently work with insurance to help your practice get paid.


Learn More

To learn more about verifying eligibility electronically in real-time, visit https://www.dentrix.com/products/eservices/ecentral/insurance-manager.

To learn more about running the Insurance Aging Report, read “Managing Your Past Due Insurance Claims” or see “Insurance Aging Report” in the Dentrix help files.


By Linda Drevenstedt, President of Drevenstedt Consulting

Linda Drevenstedt, MS, President of Drevenstedt Consulting, LLC is a consultant, a life coach, speaker, author, and webinar developer with an insightful and broad perspective. Her “Steel Magnolia” approach is honest and straightforward with a spoonful of sugar. She has real “in the trenches” experience from dental hygiene, dental assisting and managing a multi-specialty dental group practice. She holds undergraduate degrees in Dental Hygiene and Business Management and a Master’s degree in Health Care Administration. Dentistry Today has voted her a “Leader in Consulting and Speaking” for the past 15 years. Linda’s new book, Life Path by Design, is currently available on Amazon. Email her at linda@drevenstedt.com.

Originally published in Dentrix Magazine, Summer 2016