How DSOs Can Use Electronic Verification to Estimate Eligibility and Benefits, Leading to Increased Profitability and a Better Patient Experience

With an increasing number of patients using dental insurance, it's critical for dental service organizations (DSOs) to have processes and technology in place to accurately estimate eligibility and benefits at the time of service.

This is necessary to increase the likelihood of collection.

In a featured session of the Becker's Working With DSOs and Private Equity Virtual Event sponsored by Change Healthcare, Nick Deitmen, senior director for network services, and Colleen Ayala, director of dental RCM products—both from Change Healthcare—discussed eligibility verification in the DSO market and offered strategies and best practices.

Four key takeaways were:

1. Although adoption of electronic verification has increased, the dental industry still faces significant adoption challenges. Deitmen shared data showing that fully electronic eligibility and benefit verification in the dental industry increased from 51% in 2019 to 71% in 2021. However, the dental industry is still 18% below the medical industry in electronic verification.

Modernizing verification is a significant opportunity for dental providers. "A recent survey showed that dental providers waste three-quarters of a billion dollars annually through inefficient eligibility verification processes," Deitmen said. The cost savings opportunity is estimated at $839 million per year, and practices can save 10 minutes per transaction on average.

Challenges and barriers that prevent the dental industry from realizing these opportunities include inconsistent quantity and quality of 271 response data, high call volume and increased overhead due to inefficiencies, payer portal variability, and poor fee schedule access. "As a result, dental utilization continues to trail behind our medical partners," Deitmen said. 

2. Many industry stakeholders are trying to elicit change in verification processes but face difficulties. Lots of stakeholders are involved in verification and in setting standards. A dental provider office typically works with its own staff and payment management system, a clearinghouse, and a payer. Industry standards organizations include the National Dental EDI Council, the ADA Standards Committee on Dental Informatics, X12, and the Workgroup for Electronic Data Interchange—all of whom have published verification guidelines. Finally, governmental regulation is on the way with the 21st Century Cures Act, the Uniform Electronic Transactions in Dental Care Billing Act, and the No Surprises Act.

"We are still not seeing improvement because the efforts [among multiple stakeholders] are not coordinated, there are a limited number of participants, and none of the regulatory organizations have any enforcement ability at this time," Deitmen explained.

3. Best practices in eligibility and benefits verification yield multiple benefits. Best practices include providing better front-end information, which reduces the potential for denials and improves claims processes and reimbursement rates, streamlining and automating administrative tasks and keeping patients well informed.

"A healthy eligibility and benefit verification strategy enables practices and providers to increase profitability, decrease administrative burden, and improve the patient experience," Ayala said. "It also improves the staff experience, which positively impacts retention and helps grow your practice."

4. By taking proactive steps with stakeholders, DSOs can find effective solutions. "The first step is provider education, looking at the revenue cycle and how EDI [electronic data interchange] is cost effective," Ayala explained. "Then, look at how we can improve payer responses, trust and transparency, and be an advocate for positive change." Participating in standards organizations and partnering with software vendors are also important.

DSOs have an opportunity to improve eligibility and benefits verification processes by adopting EDI, working with industry organizations on standards, and educating payers and providers on best practices. Overall, this will result in greater revenue, reduced administrative work, and a better patient experience.

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