Financial Management and Reimbursement
Financial management and reimbursement tests the money trail from fee schedule to ledger to claim to collection. Expect questions on patient ledgers, accounts receivable, insurance benefits, CDT coding, adjustments, and financial reports. The administrator must separate charges, payments, contractual write-offs, and true revenue.
Ledger and reports
Post every charge to the patient ledger, then apply payments and adjustments separately. Production is treatment completed; collections are cash received; revenue is what the practice is entitled to keep. An aging report groups receivables by 0-30, 31-60, 61-90, and over-90 days. Reconcile the day sheet and bank deposit daily. Budget by category, including payroll, supplies, lab, and rent, and compare actual with budget. Know the fee schedule, the in-network allowed amount, and the contractual adjustment.
Claims and benefits
Use current CDT codes and the standard dental claim form. Verify subscriber, patient, group, frequency limits, deductibles, annual maximum, and coordination of benefits before large treatment. Submit predeterminations when appropriate. Post EOB and ERA payments line by line, track denials and timely filing, and collect patient estimates at or before service. Never promise a specific insurance payment.
Worked example
An in-network crown has a fee of $1,200, an allowed amount of $900, a remaining deductible of $50, and 20% coinsurance. The annual maximum is not exhausted. Insurance pays 80% of the allowed amount after deductible: ($900 − $50) × 0.80 = $680. The patient owes the deductible plus coinsurance: $50 + ($850 × 0.20) = $220. The contractual write-off is $1,200 − $900 = $300. The practice should collect $900 total: $680 from the plan and $220 from the patient. If the practice were out-of-network, balance billing rules and the patient estimate would need separate review.
Traps that cost marks
Posting a write-off as a patient payment; treating production as collections; missing coordination of benefits or frequency limits; filing after the payer deadline; quoting benefits as guaranteed; forgetting to collect deductibles and coinsurance; and not reconciling deposits.