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Dental Insurance Claims: 3 Ways to Stay Out of Jail

Clinical Notes and Your Role in Insurance Claim Processing

Written by Colette Jesikiewicz CDPMA, FADAA

Dental Office Assistant Duties

As a Dental Office Assistant one of your duties might include processing dental insurance claims and predeterminations. As you are completing this task, you need to remember that you are requesting money from the insurance company as payment for services rendered. Unless you have proper documentation to back up your claim you could be involved in insurance fraud.

Rules to Follow for Dental Insurance Claims

To keep yourself and your dentist out of jail you need to follow three simple rules:

1) The patient chart is a legal document. If it is not written down it did not happen. If a patient “told” you they broke a tooth eating hard candy but it is NOT documented in the patient record, then you cannot put that information on the claim form when you predetermine or charge for a crown. As a general rule of thumb, your clinical notes and insurance claim must match.

2) Document using SOAP notes. This is something that is taught in all dental schools. Unfortunately, it is common when falling into the habitual routines of a job, staff may get away from using it. Having a template such as this one that follows will help you in accurate documentation.

S – Subjective. This is what the patient tells you in their own words. This is also determined by what they say is their chief complaint. Subjectivity is based on feelings, preferences, opinions, etc.

O – Objective. Clinician observation. Documentation of what the dentist/hygienist found during the clinical exam.

A– Assessment. What is the dentist diagnosis? Differential diagnosis may also be added.

P – Plan. Written treatment plan. There may be several treatment options for each case: Treatment Plan A to replace a missing tooth may include an implant and crown. Plan B may be a fixed bridge and Plan C may be a removable partial denture. The patient needs to be given all options as well as what can happen if no treatment is done. Plan D if the missing tooth is not replaced is that the adjacent teeth may shift causing malocclusion. The treatment plan page needs to be SIGNED and dated. This will prevent the patient from coming back later and saying they were never given options.

3) Bill what you do, do what you bill. Your dentist needs to be compensated for the professional services he/she provides. If a service is provided, then charge for it. Whether or not an insurance carrier covers it does not dictate your billing. Make sure you are charging for what was actually done. Too many times offices will bill for a prophy when periodontal scaling was preformed just because the patients’ insurance will not cover the periodontal treatment. Not only will the office not be properly compensated but it is illegal! In the patients eyes it may be viewed as “just a cleaning”. Patient education is mandatory. This is where the signed treatment plan comes into play. The patient needs to truly understand the treatment before starting the procedure.

Team Player

You are a health care professional and largely work as a part of a team. Every member of that team plays a vital role in the success of the practice. If you do not see the documentation you need then ask for it. Follow up with the team members. The key is if it is not documented then it did not happen. Remember, this protects you and your dentist from committing fraud in dental insurance claims.


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