Case File #001: The Curious Case of the Missing Billing Systems
🔎 Case Summary
Every January, dental practices set goals:
Increase collections
Reduce A/R
Improve cash flow
Lower team burnout
But by March, many offices are asking the same question: “Why does it still feel like billing is broken?” The good news is that a complementary checklist is provided at the end of the article.
As The Dental Detective™, here is the hard truth:
Most billing problems do not start with insurance. They start with missing systems.
What We See in Nearly Every Audit
When a certified dental and medical biller evaluates a practice, we are not just looking at claims. We are investigating the entire revenue ecosystem.
Common findings across practices of all sizes:
❌ No standardized insurance verification process
❌ Claims submitted without a clean‑claim checklist or protocol
❌ Coding that does not fully reflect services provided (No medical-billing opportunities addressed)
❌ A/R follow‑up with no ownership or timelines
❌ Outdated or missing financial policies and consents
❌ Software being used — but not truly leveraged
None of these are “bad staff” problems. They are system gaps—and those gaps quietly drain revenue long before denials show up.
Inside a Real Billing & Systems Assessment
What does an assessment actually look like when performed by a certified billing professional?
In a 45‑minute Dental Detective™ Assessment, we review:
Practice Snapshot
Practice size and provider mix
Insurance volume and payer complexity
Medical‑dental crossover opportunities
Production & Insurance Flow
Monthly insurance collections
PPO vs OON exposure
Claim frequency and denial trends
Billing Systems & Controls
We check whether your office has:
A verification checklist
Clean‑claim protocols
Documented follow‑up timelines
Coding review processes
Upgrade compliance language
Signed and current financial policies
A/R Reality Check
Total A/R and 90+ day exposure
Follow‑up accountability
Escalation processes
Coding & Treatment Planning
Who is coding — and how
Automated vs manual risks
Whether every service provided is actually being captured
This is not about pointing fingers. It is about connecting the dots.
Why January Is the Most Important Month to Audit
January is when:
New deductibles reset
Insurance activity spikes
Small errors compound quickly
Old habits get locked in for another year
Waiting until denials pile up means you are already reacting. Investigating early means you stay in control.
The Elite Dental Systems Difference
Elite Dental Systems does not just tell you what is wrong. We:
Build billing systems
Optimize coding ethically
Integrate compliance and consents
Create accountability workflows
Support your team with structure — not overwhelm
If you want claims submitted, hire a biller. If you want revenue control, you need systems.
That is our work.
🕵️ CASE FILE #001
The Complete Dental RCM Systems Checklist
From First Phone Call → Final Payment
A smooth revenue cycle is never accidental. It is built — step by step. Use this checklist to ensure nothing slips through the cracks, no matter who is working that day.
📞 1. FIRST PHONE CALL & PATIENT INTAKE
☐ Capture full legal patient name (matches insurance)
☐ Date of birth verified
☐ Address, phone, email confirmed
☐ Employer information collected (when applicable)
☐ Subscriber relationship confirmed
☐ Primary concern identified (problem‑focused vs comprehensive)
☐ New patient vs existing patient clearly marked
☐ Referral source documented
☐ Appointment type scheduled correctly (NP Exam, Limited, Emergency, Hyg, Consult)
🗂️2. INSURANCE VERIFICATION & BREAKDOWN (BEFORE VISIT)
☐ Active coverage verified (effective dates)
☐ Annual maximum remaining confirmed
☐ Deductible (individual/family) confirmed
☐ Preventive / Basic / Major percentages verified
☐ Waiting periods reviewed
☐ Frequency limitations confirmed
☐ Missing tooth clause reviewed
☐ Downgrade language reviewed
☐ Coordination of Benefits (COB) confirmed if dual coverage
☐ Medicaid / PPO / HMO plan type verified
☐ Medical cross‑coverage potential identified (oral surgery, sleep, trauma, pathology)
☐ Copy of dental & medical insurance cards obtained
☐ Subscriber ID & group number verified
☐ Insurance notes entered clearly in PMS
📋 3. DAY‑BEFORE CHART & ROUTE SLIP PREP
☐ Appointment confirmed
☐ Eligibility rechecked
☐ Planned procedures pre‑validated
☐ Correct CDT codes reviewed
☐ Medical necessity flagged if applicable
☐ Missing documentation identified before the visit
☐ Financial estimate prepared
☐ Any prior balances addressed and notated to collect
☐ Alerts added for pre‑auth or special payer requirements
☐ Route slip printed or digitally staged
📝 4. NEW PATIENT PAPERWORK & COMPLIANCE
☐ HIPAA acknowledgment signed
☐ Financial policy signed
☐ Assignment of benefits signed
☐ Non‑covered consent signed
☐ Medical history completed & reviewed
☐ Health history changes marked YES/NO
☐ Consent language aligns with state regulations
🦷 5. BACK OFFICE HANDOFF & CLINICAL DOCUMENTATION
☐ Primary concern communicated clearly to clinical team
☐ Exam type confirmed (problem‑focused vs comprehensive)
☐ Clinical findings documented thoroughly
☐ X‑rays meet payer requirements
☐ Intraoral photos captured when indicated
☐ Periodontal charting completed (if applicable)
☐ Diagnosis supports procedures rendered
☐ Narrative requirements identified during the visit
☐ Medical necessity documented at time of service (chart notes)
💰 6. FINANCIAL CONVERSATION & CHECKOUT
☐ Copay collected at time of visit
☐ Treatment plan reviewed with patient
☐ Insurance estimate explained (“not a guarantee” language)
☐ Patient portion clearly explained
☐ Deposit collected as commitment
☐ Payment method documented
☐ Receipts provided
☐ Patient questions addressed before leaving
📆 7. SCHEDULING SYSTEMS (CRITICAL)
☐ Patient never leaves without a future appointment
☐ Hygiene scheduled as its own department
Always schedule:
☐ One hygiene appointment
☐ One treatment appointment
☐ Treatment phased logically
☐ Pre‑auth required? YES / NO
☐ Biller notified immediately of pre‑auth need
🧾 8. TREATMENT COMPLETION & POSTING
☐ Procedures posted same day
☐ Correct provider attached
☐ Tooth numbers/surfaces accurate
☐ Clinical notes finalized
☐ X‑rays/photos attached to chart
☐ Adjustments posted correctly
☐ Patient ledger balanced
🩺 9. END‑OF‑DAY DOCTOR REVIEW
☐ End‑of‑day report reviewed by doctor
☐ Production vs posting validated
☐ Daily collections allocated
☐ Missing notes identified
☐ Corrections made same day
☐ Provider sign‑off completed
📤 10. CLAIM SUBMISSION (WITHIN 24 HOURS)
☐ Claim scrubbed for errors
☐ Correct payer selected
☐ Attachments included (X‑rays, photos, narratives)
☐ Clean claim confirmed
☐ Electronic submission verified
☐ Claim batch logged
⏳ 11. PAYMENT TIMELINES & FOLLOW‑UP
☐ Expected payment window noted (7–14 business days typical; no longer than 45 days)
☐ A/R report pulled weekly
☐ Claims followed up every: 14 business days (commercial), 3–4 weeks (Medicaid)
☐ All claims over 30 days worked
☐ Communication logged (date, payer, rep, reference #)
☐ Corrective action taken as needed
📊 12. ACCOUNTS RECEIVABLE CONTROL
☐ A/R aging reviewed weekly
☐ A/R log maintained
☐ Trends identified (denials, delays, underpayments)
☐ Write‑offs reviewed & approved
☐ Patient balances addressed systematically
☐ Secondary claims submitted timely
🔄 13. CONTINUOUS SYSTEM CHECKS (OFTEN MISSED)
☐ Team trained on standardized workflows
☐ No “tribal knowledge” billing
☐ SOPs accessible and updated
☐ Metrics tracked (Days in A/R, Clean Claim Rate, Collection %)
☐ Monthly system review completed
☐ Compliance checked against payer and state rules
GRAB THE PDF VERSION OF THE CHECKLIST HERE TO DOWNLOAD (HAVE TO BE LOGGED INTO BLOG)
Final Verdict
If even one box on this checklist is unchecked, revenue is at risk. Billing problems do not start with insurance. They start with missing systems.
📂 Case Status: OPEN
Ready to Investigate Your Practice?
If you are starting 2026 asking:
“Why are claims slower than they should be?”
“Why does A/R feel out of control?”
“Are we leaving money on the table?”
Then it is time to open a case.
🕵️Book a Dental Detective™ Billing & Systems Assessment 📅 Limited January audit slots available: https://calendar.app.google/z4f26tshqpEosCdA9
Visit Elite Dental Systems: https://elitedentalsystems.com/
Subscribe to The Dental Detective™ blog: https://elitedentalsystems.com/dental-billing-blog
👉 Let’s find what is missing before it costs you another year of lost revenue.
Dental Billing - RCM Systems - Coding Optimization
