The money goes in a circle

The patient leaves at 10:40 with a new crown, and the money has barely started moving. Five jobs get it to the office, at desks she’ll never see. And then it all comes back to the desk.

Here’s one day at a dental group’s billing desk. Each hour is a different claim at a different stage, and if you put them in order, you’ve got the whole thing.

The group is invented. So is its billing lead, and so is every patient. The overnight check is the one our dental build runs today, and a person still does everything else in this story by hand.

2:00 a.m. The check.

Every office is dark while Marzy works through the upcoming schedule, opening each payer’s portal in a recorded browser session. It asks the questions you’d want a good front desk to ask. Is the plan active, and which plan pays first? What’s left of this year’s maximum, and how often will the plan pay for what the dentist has planned?

Most of the answers are boring. Boring is the goal. They land on each patient’s record, and the rest go on a list.

7:05 a.m. The list.

The billing lead gets in before the phones do. Say her name is Teresa. She used to start the day with the whole schedule and a headset, and this morning she starts with four names.

• A plan came back inactive, maybe after a new job over the summer, so the front desk will ask for the new card.
• A member ID is missing from the practice system, so there was nothing to look up.
• A crown is on the schedule for a tooth that got one four years ago, but this plan pays for one per tooth every five years.
• A patient has no insurance on file, and somebody should ask whether that’s still true.

Four names is a cup of coffee, and the whole schedule was a morning.

9:30 a.m. The claim.

A porcelain crown seated yesterday goes out as a claim, coded D2740, with an X-ray and two sentences from the dentist about a cracked cusp.

Within the hour it’s back from the clearinghouse, rejected. Nobody decided anything. The claim names the patient as the subscriber, but the plan belongs to her husband. Somebody typed that at the front desk in the spring, when she moved to his plan. Teresa fixes the subscriber and sends it again.

A rejection is a typo with a delay. A denial is a decision. But on a busy morning, they look exactly alike.

11:15 a.m. The portal.

A claim for a deep cleaning went out three weeks ago, and nothing has come back. Nothing is the most expensive answer a payer gives. Nobody notices it arrive.

Teresa opens the payer’s portal and finds the patient, then the claim, which says more information requested. The payer mailed that request twelve days ago, and it’s under the lab slips.

The cleaning is D4341, scaling and root planing. This payer won’t pay for it without a periodontal chart. The chart exists in the practice system, and nobody attached it.

We’re building this part now. Marzy will find each claim on the payer’s portal and read where it stands, so a request like this one shows up on the claim. Today, at this group, it’s Teresa and a login.

1:40 p.m. The remittance.

A payment arrives for a filling done in July, and somebody posts it line by line, writing off the gap between the office’s fee and this payer’s contract rate.

One line comes in lower still. The filling was white, on a back tooth, and this plan pays for those at the silver-filling rate. The industry calls it an alternate benefit, and it was in the plan the whole time, in a paragraph nobody reads until the payment arrives.

So the patient owes the difference. Nobody told her in July.

3:10 p.m. The denial.

A crown from last month comes back denied under the same five-year rule as this morning’s third name. This tooth got its first crown four years ago, across town. The payer knew, and the group didn’t.

The old crown broke at lunch, and the dentist prepped the tooth that afternoon, before any check could run. Teresa will appeal with the X-ray of the cracked crown. What the appeal says should stay a person’s call.

But this morning’s crown won’t end up here. Its rule came up at 7:05, so the dentist gets to decide before the drill, not after the letter.

4:45 p.m. The statement.

The last job of the day is statements. A statement can’t go out until someone posts the insurance payment, which is why your dentist’s bill can show up a month after your cleaning.

The patient with the white filling gets hers, with one line that says why. She won’t call Teresa. She’ll call the front desk, where somebody could have told her in July.

It all comes back to the desk.

5:30 p.m. The phone call.

The group’s operations director calls to ask what’s stuck. For the morning check, the list already has the answer, with a receipt beside every change, so that part of the call takes a minute.

But for everything after the check, the answer is Teresa’s memory and a stack of folders, and that takes the rest of the hour.

Line the day up.

Now pretend every hour was the same visit. The check reads the plan, the front desk types the subscriber, the claim goes out, a request waits on the portal, somebody posts the payment and the statement reaches the patient. Every link in that chain happens on a different day, often at a different desk. And each one is only as good as the one before it.

The industry calls this the revenue cycle, and the word that matters is the second one. It ends where it started, at the front desk, with a patient asking a question. The money goes in a circle.

Why we started at the front.

The check came first because every later job leans on the plan the front desk put on file. If you fix the first link, the rest get fewer surprises, though not zero.

Claims follow-up is second, since that’s where work waits quietly, like a request under the lab slips.

After that come posting, denials and the patient’s statement, in that order, because that’s the order the paper arrives.

None of it replaces Teresa. It takes the part of her day that’s a login and a search box.

It all still comes back to the desk. The point is for it to come back with the answer already on it.

Bring us the part of your cycle that’s still a login and a search box, and we’ll start with the check. Get in touch.