Specialty dental practices earn considerably more on each procedure than do general dentists, while also experiencing higher losses associated with a greater volume of billing errors. The difference in income and loss is not an accident.
2024 ADA data show that the average annual net income for dental specialists is $338,900, whereas general dentistry has an average annual net income of only $207,980. Specialty dental practices generally receive higher reimbursement amounts for each procedure due to higher reimbursement amounts from the insurance industry. This results in the documentation processes and corresponding rules and regulations being much stricter at the specialty level compared to the general level. Because of these differences in processes, a billing service that works well for general dentists may end up causing a specialty dental practice to experience significant financial losses due to denied claims, missed pre-authorizations, and compounded coding errors that occur each month.
This report will provide you with a complete list of the best dental billing services for specialty practices, along with information on what you should look for in a billing service partner you can trust with your business’s revenue cycle.
Why Specialty Dental Billing Is a Category of Its Own
While both general dental billing and specialty dental billing use the same base system (CDT codes, submission of insurance claims, processing of ERAs, and following up on AR), the way that the two categories are executed is vastly different at the specialty level compared to the general level.
The Procedure Complexity Gap
When a general dentist bills for a D1110 prophylaxis or D2150 amalgam restoration, they are billing for predictable and relatively low complexity claims. In contrast, oral surgeons billing D7210 for a surgical extraction (alongside D7310 for alveoloplasty) or periodontists using osseous surgery codes (D4260 and D4261 per quadrant) require extensive claim documentation. Each specialty has its own code sets, documentation requirements, and unique instances with each payer.
Orthodontists utilize the banding codes, retention codes, and monthly payment structures, which make billing very different from the fee-for-service specialty billing. Periodontists encounter frequency limits and medical necessity thresholds that must be documented and justified to have the scaling and root planing claim paid.
A billing company that does not have extensive specialty experience will not only underperform, but also will cost you real money on every claim that they mishandle.
Why Denial Rates Hit Specialists Harder
The denial of a $150 prophylaxis claim is painful. However, being denied for a $2,400 full-arch osseous surgery claim or a rejected pre-authorization for $3,800 for orthognathic surgery is an entirely different problem. The fact is, when you are billing specialists, the average per-claim value is significantly higher, and therefore the exposure to denial is proportionally higher.
Industry statistics indicate that dental specialty practices utilizing non-specialty billing support will experience a denial rate between 12%-20%. However, through the use of specialized CDT codes, appropriate documentation, and proactive pre-authorization workflows, the leading specialty billing companies are able to achieve denial rates below 5%.
This represents a significant difference as an example of recovery of denied claims if a dental practice has a total annual collection of $1.2 million. If a practice’s denial rate was 15% and was reduced to 4%, it would recover more than $130,000 each year.
What the Best Dental Billing Services for Specialists Actually Do Differently
As a result, you must ask the specific types of questions beyond those you typically ask for general dentistry when working with a billing partner that provides services for specialty practices.
Specialty-Specific CDT Coding Knowledge
The billing company servicing your specialty must have the capacity to discuss the code ranges specific to your specialty without pause or error. For instance, an oral surgery billing company must possess a thorough understanding of the D7000 to D7999 code range including how these codes relate to the medical billing process, such as the D-Codes and CPT Code similarities for medical procedures such as sleep apnea appliances and temporomandibular joint surgery. A periodontal billing company must possess the necessary information regarding the D4000 through D4999 coding range and the important documentation related to a payable D4341 scaling and root planing claim.
When selecting a potential billing company, ask them what specialties they actively bill for, how many accounts they currently manage within your specialty, and what their first pass claim rate is for your specific coded procedures. Beware of imprecise answers to these inquiries; they could indicate a potential problem.
Pre-Authorization Management for Specialty Procedures
Many specialist dental procedures require pre-authorization. Some of the most commonly pre-authorized types of procedures are orthognathic surgery, bone grafting, sinus lifts, sedation, and some procedures relating to implants. Billing failures, such as failure to obtain a pre-authorization, submitting gold standard documentation for the same procedure twice, and allowing an authorization to expire before a procedure has been completed, all result in a claim being denied on processed work that has been performed.
An excellent specialist dental billing service will develop pre-authorization processes and policies during the billing process of the specialty dental procedures. Verification of required authorizations will take place at the time of verification of eligibility with the insurance company, before scheduling the procedure.
Dual-Benefit and Medical Cross-Billing Expertise
Specialist dental practices tend to see a higher percentage of patients that possess both dental and medical insurance than do general dentists. Therefore, oral surgeons, periodontists, and implant surgeons routinely perform procedures that can be billed to both types of insurers. Some of the common procedure codes that can be billed to a medical carrier using an ICD-10 diagnosis code or dental CDT code include: Sedation, bone grafting for dental trauma, and dental implants for oncologic reasons (cancer patients).
Dental billing companies lack the knowledge to handle medical claim submissions for many dental specialists, leading to much loss for all specialists. The price of missed medical procedures tends to be extreme for every month the billing team is treated commensurate to their capabilities. If a billing department partner is viewed as an unimportant worker, you will not gain additional medical payments during that time period.
The Specialty Billing Mistakes That Cost Practices the Most
Missing Medical Cross-Billing Opportunities
In order for specialty practices to be successful in collecting from insurance companies, it is critical that you have open communication with the applicable billing department. Effective communication helps promote a more productive relationship, which includes efficient billing procedures.
Practices that cross-bill for specialist procedures are collecting and keeping that collected revenue that shouldn’t belong to them. Practices that only bill for dental claim submissions will continue to miss significant amounts of money each year.
Incorrect Use of Specialty-Specific Modifiers
Utilization of specialty modifiers (such as “Quadrant” for periodontal procedures, “Banding”, “Debanding”, and “Retention” for orthodontics) assists other dental practices that rely on “general practice” billing teams in submitting claims to insurance companies with few errors or denials for all specialty procedures. General practices that lack billing teams that continually pay particular attention to their daily work by utilizing the above specialty modifier code practices and submitting evidence to support their use result in billing errors.
Letting Pre-Authorization Expire Before Treatment
Scheduling specialty cases generally takes longer in comparison to general cases. Therefore, if an orthognathic surgical pre-authorization or complex bone graft approval is received in February but the procedure is scheduled later in the year, then the pre-authorization will expire before the actual surgery takes place. The best specialty billing companies keep track of the pre-authorizations expiration dates and submit renewal requests before the deadline.
How to Evaluate and Switch to a Specialty Billing Partner
Changing billing companies can be one of the highest-risk changes a specialty practice makes if not done carefully. Below are suggestions on how to change billing partners while ensuring no disruption in revenue.
Conduct a Full AR Audit First
Request a complete accounts receivable aging report from your current billing company or in-house billing team and document all open claims; include the procedure date, CDT code, payer name, claim amount, and current status. This documentation will be your reference checklist for the changeover. Your new billing partner will receive this on the first day of the billing changeover and begin working on any claims over 45 days from the date they receive it.
Run a 30-Day Parallel Period
When an agency moves from one billing provider to another, the new provider will run the new claims through its insurance company while concurrently the previous provider and/or agency will run the old receivables out. During this time, the new and old providers will work together (parallel processing) for 30 days to ensure that there is no gap in coverage for billing or to ensure that no claims fall through the cracks. Claims not worked within 60 – 90 days will quickly move into denial/ write-off status, with many specialty procedures having strict payer timeframes regarding following up on unpaid claims.
Set Performance Benchmarks on Day One
On Day One, set performance benchmarks for your new billing partner to meet over the first 90 days: Clean Claim Ratio (First Pass) above 95%; Denials below 5%, and A/R Days(average) below 35. Review these metrics every month during the first three months. If your new billing provider does not show positive progress toward reaching these performance benchmarks after 90 days, that’s valuable data to have in making business decisions.
The Right Billing Partner Changes What Your Practice Can Earn
Specialty dental practices are providing some of the most complicated, technical, high-end clinical care available in the health care sector. The revenue cycle that supports this business model must be just as complex.
The best billing service for specialty dental practices is not just any general dental billing company that has a “specialty” button on their website. A true billing service gathering the resources specializing in the procedures you treat, expertise in surgical and complex procedure coding, expertise in medical/dental cross-billing, and implementation of processes to resolve denials as if they represented billable revenue (because they do) is what you are looking for when searching for a specialty dental billing partner.
The Medicators are committed to bringing that specialty-oriented commitment for revenue cycle management to all of the specialty dental practices we serve. It does not take long for specialty dentists whose billing and collections have been managed by a generalist billing team or an in-house biller with little or no education in the specialty coding supports required for those dental practices to see and experience the benefits of having an actual specialty billing partner.
Conduct an AR Audit. Know your denial rate and the number of days in AR. Evaluate your current billing partner against the standard of billing services to which your specialty practice is entitled.
Frequently Asked Questions
What makes dental billing different for specialists versus general dentists?
Specialists will bill through a system that uses specific CDT codes. Specialists also face more stringent pre-authorizations as well as possible crossover opportunities for billing to both medical and dental insurance, which most general dentist billers have little to no experience doing.
What is the typical cost of services from specialty dental billing companies?
Typically, specialty billing services will charge between 4% and 8% of collections. Practices that are high-volume specialty need to carefully evaluate the pricing structure of using a percentage-based payment model since costs increase with additional procedures.
Is it possible to have a dental billing service perform medical cross-billings when working with oral surgeons?
Yes, some of the top specialty billing companies will perform this task utilizing a workflow that incorporates the cross-billing process by submitting appropriate claims to both dental and medical insurance, including the proper use of ICD-10 codes in conjunction with CDT codes.
What is considered to be an acceptable first-pass clean claim rate for a specialty practice?
The majority of the top specialty billing service providers will have a first-pass clean claims rate in excess of 95%. Rates below 90% of clean claims indicate a large gap in the manner in which the practices are managing their revenue cycle.
How long does it typically take to begin to see value from transitioning from billing companies?
Typically, specialty practices will begin to experience value from transitioning to a new billing company 60 to 90 days from the date of transition in terms of decreasing denial rates and improving the number of days in the accounts receivable cycle.
