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The job is not finished until the paperwork is done!

March 1, 2007
Too many dental offices have discovered the hard way that they don’t have and/or maintain valid documentation regarding financial authorizations.

by Tom Limoli, Jr.

Too many dental offices have discovered the hard way that they don’t have and/or maintain valid documentation regarding financial authorizations. With today’s reality of electronic documentation - not to mention HIPAA - all the dotted i’s and crossed t’s are being more closely scrutinized. Not only are the benefit plans watching, but your patients are expecting your office to maintain the integrity and privacy of their personal, financial, and plan-specific data.

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In the November 2006 issue of “Reader’s Digest,” Max Alexander elaborated on the all-too-common scheme of medical identity theft from the perspective of the health-care profession. Don’t simply slough off the patients’ concerns when it comes to the overall integrity of the specifics of their financial arrangements. As is simplified in our newest product, “Take It to the Bank” (, the sequential order of financial arrangements - as well as agreements - is more easily achieved with treatment plans broken down into smaller, digestible phases.

Patients receiving treatment may authorize placing of their signatures on the dental claim form by signing an authorization form known as “signature on file.” For the “signature on file” to be valid in all jurisdictions, the document must have a validation date, an expiration date not to exceed the specific series of treatment visits, as well as specific permission and justification for the billing dental entity to have such an authorization.

A “signature on file” is similar in scope to a power of attorney authorizing one individual to act as another’s agent or representative. Let’s closely examine the two specific pieces of “signature on file.” The newly revised 2006 version of the American Dental Association dental claim form maintains the same numerical references to questions No. 36 and No. 37. Nothing has changed since the 2004 version.

Authorization for payment

Question No. 37 is a simple “authorization for payment” and is not a contractual “assignment of benefits.” Having the plan subscriber direct potential payments to the billing dental office is not a guarantee that payments will be sent to the doctor. Plan-specific contract language will dictate where the payments will go.

In other words, if your office is not a designated plan provider, you will probably not get the insurance company’s reimbursement check. It will go directly to the insured subscriber or patient. Sorry, this signature is unenforceable and useless. The actual terminology reads:

“I hereby authorize and direct payment of the dental benefits, otherwise payable to me, directly to the below-named dentist or dental entity.”

Patient acceptance of financial responsibility

Question No. 36 is another story. This is where the patient, or guardian, accepts financial responsibility for the specific treatments rendered on the claim. The signatory is also granting permission to disclose protected health information relating to the payment of the claim. With this statement, you want an actual signature. With the signature as authorization, you are then free to assign the statement a “signature on file.” The actual terminology reads:

“I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in conjunction with this claim.”

When do the signatures expire? Simply put - the minute treatment is completed and the entire bill is paid! With these statements signed and dated by the insurance subscriber, patient, and/or guardian, you are now on the way to a low-stress, worry-free bank deposit.

How long do you keep the paperwork? Remember, treatment folders are for clinical data only. Check with your individual state dental association about local requirements for keeping both active and inactive patient charts. Of special concern are the charts of your former pediatric patients. Your tax accountant will let you know about how long you need to keep financial data. If you don’t ask the right person the right question, you will never get the right answer.

Financial information should not be enmeshed with the clinical portion of the record. In the event a patient exercises his or her right to inspect the clinical record and/or obtain a copy of the record, only clinical information will be available. If the record is entered into evidence as part of a legal proceeding, financial information has been known to have an adverse effect. Only financial data for the active treatment plan need be included in the treatment folder.

The returned predetermination, hard copy of the claim or TITTB form, signature-on-file cards, EOBs, laboratory prescriptions, specifics of individual financial arrangements, as well as copies of checks from both the patient and third-party payer should be filed away in a separate, chronologically logged filing system. This filing system should be indexed, based upon a completed (treatment and financial) series of visits. In other words, financial and other nonclinical data concerning completed treatment plans need not clutter and dilute the integrity of the patient record.

With the concept of phased therapy (“Dental Insurance Today,” July 2006) as background, the system of cleaning up your charts is easy to implement. When each individual treatment plan is limited or divided into a working series of visits, the paperwork falls right into place. This system of separating financial and treatment records serves a multifold purpose:

  1. The tools for tracking all those open and incomplete treatment plans are now at your disposal.
  2. The patient record is no longer cluttered with nonclinical data.
  3. Closed and completed treatment plans - with all those claim forms and EOBs - can be systematically filed away for storage.
  4. In the unforeseen event of litigation or malpractice, financial data has a greatly reduced possibility of complicating any quality-of-care issues.

Old patient financial data is simply filed away by date. The conclusion date needs to be logged in the patient’s treatment ledger so that the documentation can be easily retrieved, if necessary. Each new year, the old financial data from the previous year can be boxed for long-term storage (a minimum of seven years). Some dental offices have found it beneficial to simply file away closed financial folders at the end of each month.

Start the system with existing records. The process of initiating the use of the TITTB system is simple if you start today. Begin with today’s patients that are scheduled for either a comprehensive or periodic evaluation. What are the results of that evaluation and what additional findings or recommendations have been made? Are Mr. Gotrocks’ old amalgam fillings, with open-ditched margins, ready to be replaced? Is Mrs. Hoofnagle still taking out her lower partial when she eats pork chops? How about the banker’s six anterior teeth that are not decayed or fractured, but look horrible? These are the patients you need to start with. It is mandatory in today’s clinical practice to document and log all open treatment plans, whether they are paper or electronic (preferably electronic).

Think about all the open treatment plans in your office. Are they filed away in the patient’s record, only to be seen again when the patient returns? Or, are they potential bank deposits that will prepare your office for the future?

In this day of electronic claims, attachments, and automated records, we remind our readers that there is no substitute for an accurate diagnosis, treatment, and financial documentation. To involve oneself in this electronic age without a realistic perspective of basic recordkeeping can truly be a waste of valuable resources.

See you on the road!

Tom Limoli Jr. is the president of Atlanta Dental Consultants and the editor of “Dental Insurance Today,” a bimonthly publication that addresses third-party reimbursement in the dental office. He also is the author of “Dental Insurance and Reimbursement Coding and Claim Submission.” He can be contacted by phone at (404) 252-7808. Visit his Web site at

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