A dentist, practice owner, and self-described “billing and documentation geek” sits down with us and tells a story most of dentistry never expects to hear: Dr. Roy Shelburne was convicted and went to prison after years of investigation tied to his Medicaid-heavy practice. The numbers are not the point. The system is. If you think “we didn’t mean to” protects you, this conversation will change how you look at dental billing compliance and clinical documentation.

We dig into the uncomfortable legal reality behind intent to defraud, including “blind disregard,” where repeated errors without a system to find and fix them can be treated as fraud. From there, we get practical fast: what defensive documentation looks like before a claim is ever sent, why diagnosis must come before treatment, and how dentistry is inching toward more diagnosis-driven workflows (think ICD-10, not just CDT codes). Perio examples make it crystal clear: if the record doesn’t state the diagnosis, your SRP and inflammation-based codes are standing on thin ice.

We also talk audit triggers you can prevent today: crown claims with no justification in the chart, radiographs that are not diagnostic, and documentation gaps created when notes get entered later or copied from rigid templates. Dr. Shelburne shares how to delegate documentation safely with flexible templates, how to track non-diagnostic radiographs to improve training, and how to stop “billing to benefit” so your treatment aligns with standard of care. We close with appeal strategies, payer criteria, and the mindset that helps you get paid what you are legitimately owed while lowering risk.

If you want fewer denials, fewer clawbacks, and more peace of mind, listen, share this with your team, and then subscribe and leave a review so more practices build safer systems.

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Registration Link for Diagnosis Codes on a Dental Claim Form Webinar:

https://dentiqhub-diagnosis-codes.vercel.app/

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

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Email Ericka:
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Someone on the internet said it’s “no longer protocol” to take x-rays at recall, and that one word is where the real danger starts. Radiographs are not a habit we do on a timer. They’re part of a provider’s standard of care, and that standard of care is a clinical decision the treating doctor owns, documents, and can defend.

We walk through the practical difference between protocol and standard of care, then get specific about what the ADA and FDA patient selection guidance actually says (and what it does not say). We talk ALARA, why fixed schedules can be just as problematic as blanket “never” rules, and why the order matters every time: clinical decision first, money second. If you’re seeing more payer pushback and “clinical justification” requests, this conversation gives you language that protects both patients and the practice.

Then we get into the part billers and office managers can use immediately: what not to write in the chart or claim remarks, how fraud vs abuse is evaluated, and how an undocumented service can look identical to an unnecessary one during an audit. You’ll hear ready-to-copy narrative examples that include indication, findings, diagnosis, and disposition, plus a clear explanation of diagnosis coding, ICD-10, and how the ADA dental claim form fields (including diagnosis pointers) help a payer understand the story of the tooth.

If you want fewer denials and stronger appeals without letting insurance steer treatment, press play, share it with your clinical team, and bring your ugliest examples. Subscribe, share with a teammate, and leave a review so more dental billers can find this and document with confidence.

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Registration Link for Diagnosis Codes on a Dental Claim Form Webinar:

https://dentiqhub-diagnosis-codes.vercel.app/

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
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Email Jen:

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A lot of dental billing advice online is loud, confident, and wrong and the cost shows up months later as denials, write-offs, and clawbacks. So we flipped the mic and let you meet Erica, the person behind years of dental billing education, revenue cycle management consulting, and a whole lot of hard-won pattern recognition from inside real practices. 

We talk through her path from a “natural-born geek” who literally tried to steal homework, to becoming a teen mom who needed a stable career fast, to discovering that the dental front office was where she belonged. From there, she builds a billing company at 22, partners in dental practices, and eventually creates Dental Career College after seeing how hard it is to hire and train great front office teams. Along the way we dig into what offices actually asked for most: stronger verbal skills on new patient calls and real competence with dental insurance claims and billing systems like Dentrix. 

Then we get practical about the issues that keep practices stuck: denial management without a standard process, confusing “we did it” with “will insurance pay,” and letting coverage rules creep into clinical decision-making. Erica shares why billers must keep up with updated CDT codes, invest in continuing education, and prepare for diagnosis codes and AI in dentistry, because the billing landscape is changing fast and it will leave people behind. 

Follow us for tips and updates, and don’t miss the upcoming live webinar: bring your denials and your questions. If this helps, subscribe, share the episode with your office, and leave a review so more dental teams can find it.

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Registration Link for Diagnosis Codes on a Dental Claim Form Webinar:

https://dentiqhub-diagnosis-codes.vercel.app/

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
[email protected]

Email Jen:

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The fastest way to break a dental billing system is to assume the hard part starts after treatment. We sit down with Jen Lyman, now officially my co-host, and get honest about what really determines whether your dentistry turns into clean reimbursement: credentialing setup, correct identifiers, accurate provider records, and documentation that can actually support what you code.

Jen shares her path from full-time clinical hygiene to building Lyman Revenue Solutions, including the burnout and physical strain that pushed her out of the chair and into the revenue cycle world. From there, we dig into the credentialing pitfalls we see constantly, especially the Type 2 NPI issue that feels “optional” until you add an associate, open a new location, or stop practicing. We talk about how contracts tied to the wrong entity create messy fixes, compliance risk, and audit exposure that can reach years back.

We also get practical about operations: why provider list cleanup and fee schedule maintenance almost never happen inside practice management software, and how a monthly “billing CEO day” can prevent denials and confusion. Then we go deeper into coding and documentation, including the debates around CDT codes like D0180 and D4346, why coding is not the same thing as coverage, and why diagnosis codes on the dental claim form are becoming non-negotiable. If you want stronger claims, fewer surprises, and a team that speaks the same language from chairside to the front desk, this is for you.

Subscribe, share this with your office manager or lead hygienist, and leave a review so more dental teams can find the show and fix the problems that never should have started.

Send us Fan Mail

Registration Link for Diagnosis Codes on a Dental Claim Form Webinar:

https://dentiqhub-diagnosis-codes.vercel.app/

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
[email protected]

Email Jen:

[email protected]

Insurance paperwork is eating the front office alive, reimbursements keep tightening, and expenses keep climbing, yet many practices still feel stuck on the PPO treadmill. I sit down with Jordan Comstock, founder and CEO of Boom Cloud, to talk about a strategy that gives dentists real breathing room: building an in-house patient membership program that creates recurring revenue and reduces dependence on dental insurance PPO plans over time.

Jordan shares the blunt numbers driving the pressure, then walks through what a membership plan looks like when it’s treated as a serious business asset instead of a “cute” discount sheet. We talk through a practical path many offices miss: grow the membership base first, create a financial safety net, then make payer changes with confidence. Along the way we dig into surprising case acceptance data comparing cash patients, PPO patients, and membership patients, plus why predictable collections on the first or fifteenth can change how you sleep at night.

We also get honest about why DIY membership plans often collapse under manual tracking, forgotten billing, annual churn, and lack of reporting and how automation, staff training, and incentives make the difference. Jordan explains how Boom Cloud uses integrations and data-driven pricing to speed up launch and help teams actually scale to hundreds of members, which can improve cash flow, resilience during downturns, and even practice valuation when it’s time to sell.

If you want a clearer, less stressful way to grow profitability without begging insurers to change, listen all the way through. Subscribe, share this with a practice owner who’s fed up with PPOs, and leave a quick review with your biggest question about membership plans.

Send us Fan Mail

Registration Link for Diagnosis Codes on a Dental Claim Form Webinar:

https://dentiqhub-diagnosis-codes.vercel.app/

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
[email protected]

Email Jen:

[email protected]

Delta Dental’s logo is everywhere in dentistry, but the numbers most practices never see are sitting in plain sight in a federal CMS dataset. We walk through the CMS Transparency in Coverage Public Use File and focus on the rarely opened tab for individual marketplace standalone dental plans. Because carriers self report claims received, denials, resubmissions, and formal appeals, the file becomes an uncomfortable mirror for both payers and the dental billing systems we run inside our offices. 

Here’s what stops us: Delta Dental companies across 20 states report a 22.5% in network denial rate, higher than the broader dental market in the same file, and out of network denial rates climb even further. But the real gut punch is what CMS added for 2024: resubmitted claims. When only a small fraction of denied claims come back through the door, it suggests a huge pool of abandoned revenue sitting on aging reports, quietly turning into write offs and patient balances without a deliberate decision. 

We also get precise about formal appeals: what counts, why plan documents matter, how deadlines create leverage, and why regulators only have visibility when we generate a paper trail. Then we turn it into action with a practical denial management process, simple tracking fields your team can start this week, and a challenge for practice owners to stop accepting “I need to appeal those” as the end of the conversation. Subscribe, share this with your billing team, and leave a review with one change you are making after you pull your last 90 days of Delta denials.

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Registration Link for Diagnosis Codes on a Dental Claim Form Webinar:

https://dentiqhub-diagnosis-codes.vercel.app/

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
[email protected]

Email Jen:

[email protected]

Less than 1% of denials get appealed in the real world, yet regulators have found appeal reversal rates that should stop every dental office in its tracks. We pull apart what that contradiction tells us: denials are not just “one-off mistakes,” they can be a business model that survives on provider exhaustion, unclear standards, and paperwork loops that quietly delay payment until you give up.

We walk through the hidden source material most billers never read market conduct examinations, consent orders, and enforcement actions where the state audits the insurance carrier and publishes what it finds. From “sequential” documentation requests to denial language that fails to explain what would make a claim payable, these reports turn gut feelings into quotable evidence. We also explain why a fine is effectively a written confession: it shows which behavior could not survive an audit and gives you leverage to reverse engineer your next appeal and escalation.

Then we get practical. Clean claim is a legal term tied to prompt pay law, and understanding it changes how you respond to additional information requests designed to stop the clock. We share two calm questions you can use immediately: ask for the filed policy provision that supports the denial, and ask which licensed clinician reviewed the claim and whether they reviewed the submitted documentation. Finally, we zoom out to pattern recognition: denial rates, overturn rates, time-to-payment, and filing complaints with the right regulator based on plan type, including ERISA self-funded plans and the US Department of Labor.

If you want smarter dental billing appeals and stronger denial management, listen now, subscribe for more, and share this with a biller who is tired of water-gun tactics. What denial pattern are you seeing most in your office?

Send us Fan Mail

Registration Link for Diagnosis Codes on a Dental Claim Form Webinar:

https://dentiqhub-diagnosis-codes.vercel.app/

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
[email protected]

Email Jen:

[email protected]

A huge amount of dental practice revenue doesn’t disappear because patients refuse to pay or because insurance “just won’t cover it.” It disappears because someone clicks an adjustment code and the money evaporates without a clear name, a written policy, or a second look. That quiet leak is what I call adjustment slop, and once you learn to spot it, you won’t be able to unsee it.

We start by separating two concepts that too many offices blur together: write offs versus adjustments. Write offs are contractual and tied to your PPO fee schedule. Adjustments are choices, like courtesy discounts, employee perks, hardship cases, marketing promos, or quick “fixes” that make an awkward balance go away. When everything gets dumped into one generic bucket, you lose the story your data is trying to tell. You can’t manage what you can’t see, and you definitely can’t make smart decisions about participation, profitability, or team habits.

Then I walk you through the five types of adjustment slop I see when I take billing departments apart: habit adjustments, cover up adjustments that bury unworked claims, lazy courtesy with no authority, “corrections” that hide posting errors, and bad debt adjustments that happen before real collection steps. You’ll also get my teardown method you can do tonight: pull a 12 month adjustment report, sort by type, and ask one yes or no question for each label: is there a written policy behind this?

If you want your billing reports to be real management tools, not financial guesswork, hit play, pull your report, and start labeling money with intention. Subscribe, share this with your office manager, and leave a review if it helps you stop the leak.

Send us Fan Mail

Registration Link for Diagnosis Codes on a Dental Claim Form Webinar:

https://dentiqhub-diagnosis-codes.vercel.app/

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
[email protected]

Email Jen:

[email protected]

Less than 1% of denied dental claims ever get appealed and insurance companies are counting on you to be in the other 99%. I walk you through the denial management mindset shift that changes everything: stop treating the third appeal like the edge of the map and start using the tools that actually hold payers accountable, including your state insurance commissioner for fully insured plans. 

We get practical and specific about what makes a denial “unreasonable” or “bad faith” and how to spot the pattern: benefits are active, eligibility is confirmed, documentation supports dental necessity, and the claim still comes back denied. I also explain why we start with state and federal laws before we obsess over codes, because language like prompt pay, network leasing, and silent PPO issues gives your conversations more weight. Then we clean up common risk areas by separating an honest mistake, a contract violation, and fraud, because mixing those up can put a practice in real trouble. 

From there, we talk tactics: why copy-and-paste appeal templates can work against you in a world where insurers use AI to review claims, and what to use instead. Think ICD-10 diagnosis codes, strong narratives, and patient-specific clinical details that make your claim defensible. Finally, I share documented enforcement examples, including a major fine tied to undisclosed “phantom” frequency limits, and why complaints to regulators compound over time. 

If you want a denial process that protects patients and stops leaving money on the table, listen all the way through, then subscribe, share this with your office team, and leave a review so more billers learn how to escalate the right way.

Sources referenced in this episode:

• Appeal rate / upheld rate: KFF analysis of CMS data — fewer than 1% of denied ACA marketplace claims are appealed; insurers uphold ~56% of appeals (2023 data), 66% (2024 data). Medicare Advantage: ~57% of appealed denials overturned. (On air we used these instead of the "59% upheld because nobody appealed" framing, which conflated the appeal rate with the uphold-on-appeal rate.)
• Delta Dental of Washington: Washington State Office of the Insurance Commissioner fined Delta Dental + its health care benefits manager (Wyssta) $130,000 (Oct/Nov 2024) for, among other things, denying claims based on time/frequency limits not filed with or approved by the state; 7 service types and 50 billing codes had undisclosed limits. Triggered by consumer complaints. This is an actual regulatory fine.
• Self-funded vs. fully insured (the "federal path" mention): The commissioner regulates fully insured plans. Self-funded employer plans fall under federal ERISA law and route to the U.S. Department of Labor (EBSA) instead, not the state commissioner. This is covered in depth in the full denial management talk, not this episode. (Government and church plans are a further exception.)
• Cigna PxDx: 2023 class action (E.D. Cal.), citing ProPublica reporting — ~300,000 denials in two months, avg. 1.2 seconds per claim, "we literally click and submit." Court allowed the case to proceed March 2025 (abuse of discretion). This is litigation, not a fine — described on air as a lawsuit/court ruling.
• UnitedHealth nH Predict: Class action (D. Minn.) alleging a 90% error rate on the AI tool and that ~0.2% of policyholders appeal. Court ordered algorithm disclosure in 2026. Allegations in active litigation — stated as such on air.
• The "0.2% will appeal" motive appears in both the Cigna and UnitedHealth complaints as an allegation of intent.

Send us Fan Mail

Registration Link for Diagnosis Codes on a Dental Claim Form Webinar:

https://dentiqhub-diagnosis-codes.vercel.app/

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
[email protected]

Email Jen:

[email protected]

Dental billing can look smooth from the outside, but that “smooth” is usually one person doing a mountain of detailed, high-stakes work behind the scenes. We’re sharing a quick, focused message about Dental Billers Appreciation Day and why it matters for every practice that depends on clean claims, accurate coding, and steady collections. 

You’ll hear how a conversation with Qiana Craig (Ask the Biller) about Medical Billers Appreciation Day sent us down a research rabbit hole and revealed something surprising: dental billers didn’t have a day of their own. So we created one. That story opens up a bigger theme we live by in dental office administration and practice management, if you don’t see the space you need, build it. 

We also get real about what the job requires: deep organisation, constant follow-up, tech skills across modern billing tools, and the discipline to keep up with changing codes and systems in today’s dental economy. Dental revenue cycle management doesn’t run on luck, it runs on expertise. Dental Billers Appreciation Day is July 20 every year, so mark your calendar and do something meaningful for the person who helps keep your practice financially healthy. If this resonates, subscribe, share it with your team, and leave a review so more dental offices start giving billers the credit they’ve earned.

Send us Fan Mail

Registration Link for Diagnosis Codes on a Dental Claim Form Webinar:

https://dentiqhub-diagnosis-codes.vercel.app/

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
[email protected]

Email Jen:

[email protected]