A gap in dentist knowledge could be contributing to delays in the claims reimbursement process and denials, according to Dominique Fufidio, DDS.
Dr. Fufidio recently founded Fufidio Consulting Group to help dental offices understand the insurance claims process with the goal of reducing delays and denials. She recently spoke with Becker's about her new company and the challenges among dentists and payers.
Editor's note: Responses were lightly edited for clarity and length.
Question: When did the idea for this company start?
Dr. Dominique Fufidio: The full idea came to me only about three months ago. I've been thinking about a version of this company for a while, but it was when I was attending a workshop with my local dental society that others were coming up to me saying they wanted to learn everything that I knew about insurance, starting up and selling a practice, as well as artificial intelligence in the dental market. I tried to schedule all of these as appointments and realized I couldn't give back to the community the way I wanted unless I made this my full-time passion.
Q: What were some of the top questions you received from dentists before you started your company?
DF: A lot of general practitioners as well as those specializing in periodontics were coming to me specifically about their scaling and root planing claim denials. [Providers] were reporting these claims as particularly challenging to be reimbursed for. I can understand why. No one really teaches the actual requirement of visible, radiographic, bone loss on X-rays for the teeth and quadrants submitted, but also that this bone loss typically needs to exceed a measurement of 2 millimeters when evaluating the distance from the CEJ to the crest of bone. I'm [also] constantly hearing how core buildups are denied. After transitioning to the insurance payer market, I realized dentists routinely bill out the CDT code D2950 when by definition they're actually performing what's called a D2949, more a filler of an undercut, not a true requirement for crown retention. There's some misalignment and a gap between the dental providers and the dental insurance market, and also, in some parts, traditional education. I'm hoping to bring clinical alignment.
The decision-makers at these insurance companies care about the patients and the patients being entitled to all of their benefits, but patients can't be entitled to more than what their benefit agreement is. Clinical claim reviewers recognize dentists are inherently good people. A lot of times offices are simply missing submitting what they need in order to meet the criteria for payment. Insurance companies have recognized it's not a loss for them to pay out on the medically necessary dental treatments, they expect to, but it does have to be demonstrated in the documentation. It's a large waste of overhead and a source of frustration for all parties to keep receiving appeals, have to do peer-to-peer phone calls and go back and forth on these claims when if the appropriate documentation was submitted the first time and approved instead of after the back and forth, it would actually be a lot more profitable for everyone and promote a more positive overall experience.
Q: Why aren't dentists taught more about the insurance claims process?
DF: Dentistry is very technical. It takes more than four years of dental school to feel competent when treating patients. There's so much clinical information we need to learn and when you're going into practice, your expectation is you'll be able to focus on clinical dentistry and have team members who are able to work on these other parts of making the business run.
I have colleagues who knew nothing about what a claim form looked like and realized they didn't know how to run the front office at all when they purchased their practices or started up. I was included. Dentistry is niche; there's not enough time to learn what is typically considered a front-office administrative skill, but the foundational materials for these submissions are clinical documents and records.
Also, software is constantly changing. The field is evolving, technology's being incorporated, and the CDT codes and the claim form itself are updated. Some insurance companies have different versions of the form. So it's a continuous educational process, and there's just not enough time in a traditional four-year curriculum postdoctorate program, and when you get right into practice, to learn it.
Q: How has your experience as a dentist informed your business strategy and goals for the company?
DF: I pitched my idea to [a contact] I've worked with over the years and they recommended doing a webinar or continuing education seminar to get my ideas out there and impact a large audience quickly. I visited my former office and referenced patient-specific claims ingrained in my memory from having to go back and forth with the insurance company too many times. I pulled the appeals and I was surprised with how much information I was giving the insurance companies. In one case, [after] three appeals, I finally touched upon what the payer was actually looking for. Even though I had submitted pages and pages of documentation, there was really only one thing they needed to know to approve my claim. Now that I know there are criteria insurance companies are looking for, I recognize the importance of reading the EOB language to see what the actual question is the insurance company has and answer just that. I don't need to tell them everything else because they're looking to just have validation on that one certain criteria so they can make the recommendation for benefits.