Navigating the Complex World of Dental Insurance Verification Outsourcing

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Navigating the Complex World of Dental Insurance Verification Outsourcing

Outsourcing dental insurance verification has become an increasingly popular choice for dental practices as they seek to optimize their operations, reduce costs, and improve patient satisfaction.

With a multitude of options available, it is essential to understand the various approaches to insurance verification and how they can impact your practice.

This comprehensive guide will explore the four main categories of dental insurance verification services, including their strengths and weaknesses, and provide a set of questions to help you determine which solution best aligns with your practice's needs.

Clearinghouse/EDI Dental Insurance Verification

One of the cheapest options for insurance verification is using a clearinghouse, which leverages Electronic Data Interchange (EDI) or Application Programming Interface (API) connections with insurance companies to obtain benefit information. These services are often included in monthly clearinghouse subscriptions, but they require a staff member to lookup, interpret and transfer insurance plan information to the practice management software.

What is EDI?

EDI, or Electronic Data Interchange, is a method used in dental insurance for the electronic exchange of information between dental offices and insurance companies. By employing standardized formats, EDI enables dental offices to submit claims, inquire about claim status, receive payment details, and verify patient eligibility for coverage. APIs solve a similar need but offer some advantages over EDI in terms of flexibility, costs, and response times. I’ll cover this in more detail in another article.

While this technology facilitates the automation of administrative and financial tasks, it may also present drawbacks such as potential inaccuracies due to “out of sync” databases, lack of insurance details that are not available electronically, limitations in customization, and an overall unclear formatting of the eligibility information. The eligibility responses provided are in a generic multi-page format, and typically don't take into consideration the provider’s network status when displaying insurance plan information. This information will then need to be interpreted and parsed by a staff member, and manually transferred to the practice management software. Also, not all insurance carriers have adopted EDI, so there will still be times when a phone call will need to be made.

Examples of companies in this category include Vyne Trellis, Dental Intel, Weave, Zuub, and DentalxChange.

Automated Dental Insurance Verification

Another cost-effective option is automated insurance verification. These services integrate directly with your Practice Management Software (PMS) and write back insurance information directly to the patient’s insurance module, primarily without human intervention. Fully automated verification services typically use a combination of electronic eligibility (EDI or API) and RPA (Robotic Process Automation). However, fully automated verification services can struggle with unusual insurance plans, frequent schedule changes, and detailed information that necessitates phone calls.

In a perfect world, automated dental insurance verification would be the ideal solution. However, there are still many challenges to overcome before automation will be a reliable and comprehensive means of dental insurance verification.

Dental insurance is a collection of disparate systems, cobbled together slowly over many years. There is little standardization across insurance plan structures, a multitude of practice management software’s that require integration, and a wide variety of network participation and practice needs. All of these things are inconducive to a stable, comprehensive automated insurance verification service. Automation is a two-way street that depends on the participation and cooperation of the insurance carriers, otherwise it is an uphill battle to consolidate and translate insurance plan breakdowns to a standardized format.

Pay-per-Verification (PPV) Dental Insurance Verification

Pay-per-Verification is a popular choice for practices that want more control over their insurance verification process, while also providing a means of off-loading most of the legwork. This model requires the practice to request verifications for specific patients and determine the level of detail needed. Since it follows an a-la-carte pricing model, additional fees may apply if the patient's insurance is not active or if there are issues locating the patient's plan.

PPV can be a valuable approach if there are already established insurance verification protocols in the office. However, if there are frequent schedule changes or the office lacks standardized insurance verification processes, the possibility of patients being overlooked or unverified can become an issue. Companies offering this service usually provide both Do-It-Yourself and Done-For-You options for data entry into the PMS.

Examples of companies in this category include eAssist, EZ Dental Billing, Reach, and Medusind.

Full-Service Dental Insurance Verification

A comprehensive solution for dental practices is a full-service verification model, which involves a dedicated remote “insurance coordinator” managing the entire insurance verification process. Dentalogic has pioneered this model, providing a dedicated account manager who works directly with your staff on a daily basis. This option is billed at a flat monthly fee, with no additional charges for same-day patients or schedule changes.

While full-service verification is more expensive than other options, it essentially provides an additional employee who is always available to assist with insurance verification tasks. Dentalogic is unique in the fact that all our employees report to a centralized office in the US. We don’t outsource labor overseas, and we provide a high level of oversight to the daily operations.

One significant benefit of full-service verification is the ability to reallocate staff time to more crucial tasks, such as patient care and case acceptance. By outsourcing insurance verification completely, your team can focus on creating a better patient experience and increasing revenue for the practice. Additionally, full-service verification companies often have greater expertise in insurance verification, enabling them to navigate complex policies and provide accurate information.

"I usually recommend being on one end of the spectrum or the other. In my experience, automated or pay per verification don't end up as long-term solutions for a practice.

Large practice or small group should fully outsource to a company like Dentalogic as it creates a scalable model for the entity as it grows. Inevitably, if you have the process internalized you hit a wage-to-productivity ratio that exceeds the pricing structure that full-service companies charge for services.

Plus, you are not left in an immediate hire scenario that greatly affects RCM using an outsource company. I have seen numerous times where an insurance coordinator gives two weeks and there is no back up plan for the transition event."

-Vincent Crump, Midline Dental Partners
Determining the best dental insurance verification solution for your practice depends on your goals, resources, and desired level of involvement in the process.

If you are looking for a cost-effective tool to augment your staff's tasks, EDI or automated solutions may be suitable. On the other hand, if you want to completely outsource the process, a full-service verification company with deep expertise in the field may be the best choice.

To help you make an informed decision, consider the following questions:

  1. Do I have a staff member knowledgeable in insurance verification who just needs a technology tool?
  2. Is there a plan in place if that staff member is out sick or decides to leave?
  3. Is there inaccurate data that needs to be cleaned up?
  4. How much time is my staff spending on phone calls to insurance companies?
  5. Are there specific aspects of the insurance verification process that my staff finds particularly challenging or time-consuming?
  6. If problems arise with errors, how is this handled?
  7. Do I need a company to enter the data into my PMS directly?
  8. How often does my practice encounter unique or complex insurance plans that may require specialized expertise?
  9. Would a "full-service" verification company allow me to shift my staff's focus to other more important tasks?

By carefully evaluating your practice's needs, you can choose the most appropriate dental insurance verification outsourcing solution to optimize your operations, reduce costs, and ultimately enhance patient satisfaction.

Keep in mind that as the industry continues to evolve, new technologies and services may emerge to further streamline the insurance verification process. Staying informed and adaptable will ensure your practice remains competitive and efficient in the ever-changing landscape of dental insurance verification.

Wyatt Broxson
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