Revenue Cycle – Differences Medical vs Dental
My first venture into the dental side of healthcare was in 2013. Coming from a history with large health systems, both for profit and not-for-profit, as well as serving in the outpatient specialty sector, I found dental quite interesting.
Within a few months of work, my CEO at the time asked what I saw as the differences between medical and dental from both a Revenue Cycle and industry perspective. In that conversation, I found that dental providers believe that medical providers “have it made”. Of course, I had also heard from medical providers believing that dental providers “have it made”. I guess the grass is always greener.
Here’s my assessment then, and fast forward to 2024, what I see now.
Plan Architecture and Coverage Philosophy
In dental plans, benefits are structured like a vending machine. Each service has a limited number of benefits. Once these benefits are exhausted or the maximum coverage amount is reached, the coverage ends. On the other hand, medical plans operate like an expansive ocean of coverage. However, accessing these benefits requires meeting the criteria of medical necessity, supported by clinical documentation that justifies the service as necessary for the patient's health.
Benefit Architecture and Code Sets
Medical services are categorized by type, such as inpatient, outpatient, surgery, etc., with benefits aligned accordingly. Dental benefits, however, are organized by specific procedure codes, making the benefit structure simpler and more straightforward.
Diagnosis Code Usage
While medical claims heavily rely on specific diagnostic codes (ICD-10) to process claims, dental claims typically do not require such specificity for claim processing. This emphasis on diagnosis codes in medical claims stands in contrast to the dental industry.
Co-Morbidities
In medical visits, co-morbidities play a crucial role in painting a comprehensive healthcare picture. Medical providers address secondary diagnoses beyond the primary issue to understand the patient's overall health. On the other hand, the incorporation of co-morbidities is less prevalent in dental care as dental practices often focus on problem-focused diagnoses.
Patient Responsibility
Dental services often require a higher patient responsibility component, with patients contributing a significant portion of the reimbursement. In contrast, the patient's financial responsibility in medical services typically constitutes a smaller percentage of the total cost.
Complexities With Code Sets on Claim Forms
Medical claim forms introduce a myriad of modifiers and codes compared to dental claim forms. Medical billing processes require a deep understanding of the coding nuances and extensive use of modifier codes.
Summary and Conclusion
Understanding the revenue cycle differences between medical and dental practices is crucial in navigating the complexities of each sector. Medical and dental revenue cycles have distinct characteristics, such as plan architecture, benefit organization, code usage, co-morbidity considerations, patient responsibility, and claim form complexities. Providers transitioning between these two sectors may benefit from expert guidance to effectively navigate the intricate nuances of revenue cycle management.
To conclude, navigating the intricate differences between dental and medical revenue cycles requires expertise and innovative tools. CareStack, the leading dental practice management solution, and CareRevenue's Dental RCM services empower dental practices to bridge these complexities, streamline their operations, and achieve higher efficiency. By combining cutting-edge technology with specialized RCM expertise, these solutions enable practices to maximize their revenue potential while ensuring compliance and simplifying workflows.
Take the next step toward transforming your dental practice—connect with CareRevenue today and experience the difference!
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