Someone Kandra Sellers knows retired from dentistry, developed cancer, and received a message from his insurance company the following January: They had paid just under $1 million in claims for his treatment the previous year. No annual maximum. No benefit cap. No letter saying his coverage had run out.
That story opens this second episode with Sellers -- a retired clinical hygienist and founder of TIPS Medical Billing -- and it illustrates the scale of what dental practices are leaving behind. Editor-in-Chief Kevin Henry sits down with Sellers again to go deeper, and the conversation moves quickly from philosophy to practice.
The most striking moment in the episode is not a statistic. It is a story Sellers relates from the morning the podcast was recorded. Sellers had just received confirmation that a prior authorization for a complex reconstructive case -- jaw surgery, bone grafting, sinus lifts, implants, cyst removal, and excision for osteomyelitis -- had been overturned on appeal. A reviewing dentist in the payer's prior authorization group initially classified the procedures as dental in nature. Sellers pushed back, hard. A medical doctor within that same group reviewed the appeal, disagreed with the original decision, and confirmed that the treatment was medical. The prior authorization was cleared and sent back for reprocessing.
Her framing of that moment is worth paying attention to: The payer was discriminating against a provider type. Government statutes exist that prohibit that. Sellers knew that and said so.
That confidence comes from understanding what the codes actually say. The implant codes used in a full reconstructive case are reconstructive codes -- the same codes a medical doctor could use for the same procedure on any other part of the body. The only reason they were questioned in this case was that the provider had DDS behind their name. That is the conversation practices need to be equipped to have with payers, and it is the conversation most practices are not having at all.
For practices wondering where to start, Sellers' answer from this episode is consistent with the message from her first visit: documentation and diagnosis codes. Everything that follows depends on both of those two items being correct.
Listen to the full conversation below.
