> ## Documentation Index
> Fetch the complete documentation index at: https://dso.getlemma.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Hire your first biller

> Evaluate dental billers for CDT knowledge, downgrade handling, COB, attachments, predeterminations, and appropriate compensation incentives.

A capable dental biller has a direct effect on net collection rate. Look closely at how candidates handle downgrades, initial attachments, and patient estimates because those details often separate reliable performance from routine claim follow-up.

## Prerequisites

* Your PMS and clearinghouse selected
* A decision that in-house billing fits your group; see [In-house vs. outsourced RCM](/guides/billing/in-house-vs-outsourced-billing)
* The DSO registered as an employer in that state

Assign the biller to the entity permitted by the state's dental and employment rules and the agreement stack. Regardless of employer, the biller runs the administrative workflow while the treating dentist retains any clinical coding authority required by state law. Document the allocation in the management services agreement (MSA). See [What a DSO can and can't do](/concepts/model/what-dsos-can-and-cant-do).

## Define the role

At a single-biller office, the role spans the whole cycle:

| Phase         | Responsibilities                                                                        |
| ------------- | --------------------------------------------------------------------------------------- |
| **Front end** | Benefits verification against plan design, predeterminations, insurance data quality    |
| **Middle**    | Charge entry, attachments and narratives, claim submission, rejection resolution        |
| **Back end**  | Payment posting that separates denials from downgrades, appeals, insurance AR follow-up |
| **Patient**   | Statements, balance calls, payment plans, refunds                                       |
| **Reporting** | Weekly dashboard, denial and downgrade root-cause tagging                               |

Define the role's boundaries, including clinical code selection, PPO fee negotiation, and credentialing. If the biller will also handle one of those functions, say so expressly and preserve required professional authority.

## What competence looks like in dental

Dental billing does not have one dominant credential comparable to the AAPC's CPB or CPC. A general billing certification can show process knowledge, but it does not establish dental fluency. Screen for these five skills:

* **CDT fluency.** Understands the code categories, the January 1 annual update, and the need to use the version effective on the date of service. See [CDT and the 837D](/reference/edi/cdt-and-837d).
* **Downgrade and LEAT literacy.** Recognizes an alternate-benefit payment on sight, knows the difference is patient responsibility rather than an appeal or a write-off, and knows what the financial consent must say for that to hold.
* **COB and the birthday rule.** For a dependent child under two plans, the primary plan is generally the plan of the parent whose birthday falls earlier in the calendar year, using month and day rather than age, subject to superseding court orders.<sup>1</sup> Test whether the candidate knows how to verify primacy instead of guessing.
* **Attachment workflow.** Knows which procedures commonly require documentation, including crowns, scaling and root planing, buildups, and implants. The candidate should understand how an attachment reference travels with the claim.
* **Predetermination discipline.** Knows that a predetermination is a voluntary estimate adjudicated at the date of service, while some payers require preauthorization. See [Get predeterminations](/guides/billing/get-predeterminations).

Give substantial weight to experience with **your PMS** and **your payer mix**, including the relevant Delta member companies and Medicaid dental administrator.

## The interview exercise that works

Hand the candidate a **redacted dental 835** containing a downgraded posterior composite, a frequency-limit disallowance, a CO-45 contractual adjustment, and a PLB takeback. Ask them to walk you through it.

You are listening for:

| Do they…                                                                                     | Signal                                   |
| -------------------------------------------------------------------------------------------- | ---------------------------------------- |
| Distinguish CO from PR correctly?                                                            | Fundamental. If not, stop.               |
| Recognize CO-45 as the normal PPO write-off rather than a problem?                           | Understands contractual adjustments      |
| Identify the downgrade and apply the contract and financial-consent terms to the difference? | Shows practical dental posting knowledge |
| Treat the frequency disallowance as benefit design, not a denial to appeal?                  | Understands plan design                  |
| Notice the PLB and explain why the deposit won't match?                                      | Genuinely experienced                    |
| Ask what the remark codes say?                                                               | Thinks in specifics                      |

A candidate who handles that fluently can do the job. One who cannot will cost more than their salary in donated downgrades and unworked patient balances.

**A second exercise:** "A crown claim came back requesting radiographs and a narrative. What happened, and what do you do?" You want to hear that the attachment should have gone with the original claim, how they'd send it now, and how they'd fix the workflow so the next crown doesn't repeat it.

## Compensation

Highly market-dependent. Directional ranges for a single experienced dental biller:

| Level                       | Typical range   |
| --------------------------- | --------------- |
| Entry, front-desk crossover | $38,000–$48,000 |
| Experienced dental biller   | $48,000–$65,000 |
| Senior / lead, multi-office | $60,000–$85,000 |

Add 20–30% for benefits and payroll taxes to get loaded cost. Adjust substantially for high-cost metros and for remote hiring.

<Tip>
  **Do not structure billing compensation in a way that rewards aggressive coding.** Consider measures such as clean-claim rate, days in AR, or point-of-service collection discipline instead of total collections. Production-linked incentives have appeared in dental False Claims Act matters. See [Billing compliance basics](/concepts/compliance/billing-compliance-basics).
</Tip>

## How many billers

Measure the work rather than relying on a staffing ratio alone. Track whether claims and attachments go out promptly, rejections are worked the same day, the denial queue has no items over 14 days, allowed downgrade balances reach patients within a statement cycle, and AR remains stable. Add capacity when these measures begin to slip. As offices accumulate, repeated payer and posting rules may support a centralized team instead of one biller per office.

## Steps

<Steps>
  <Step title="Write the role description with the phase table above" />

  <Step title="Source for dental payer and PMS experience first, credentials second" />

  <Step title="Screen on the 835 exercise">
    Do this early. The downgrade line eliminates candidates faster and more reliably than a resume review.
  </Step>

  <Step title="Check references on specifics">
    "How did they handle downgrades and frequency limits?" and "what was their attachment first-pass rate?" rather than "were they good?"
  </Step>

  <Step title="Set up the daily and weekly checklists before they start">
    See [Build the billing rhythm](/start/first-90-days/build-the-billing-rhythm).
  </Step>

  <Step title="Define the escalation path for documentation concerns">
    Your biller must be able to raise a documentation or coding concern to the dentist **without going through DSO operations**. This is both a compliance control and the mechanism by which a concerned employee raises an issue internally rather than becoming a qui tam relator. See [Billing compliance basics](/concepts/compliance/billing-compliance-basics).
  </Step>

  <Step title="Plan for coverage">
    A single biller is a single point of failure. Cross-train someone, or arrange overflow support before you need it.
  </Step>
</Steps>

## Verify it worked

* [ ] Role description written and scoped
* [ ] Candidate screened on the dental 835 exercise, downgrade line included
* [ ] Dental payer and PMS experience verified with references
* [ ] Employed by the **DSO**, with the state registration in place
* [ ] Compensation not tied to collections or production in a way that pressures coding
* [ ] Daily and weekly checklists in place before day one
* [ ] Escalation path to the dentist defined
* [ ] Coverage plan for absence

## Common failure modes

| Failure                                        | Consequence                                                     |
| ---------------------------------------------- | --------------------------------------------------------------- |
| Hiring on credentials without the 835 exercise | A biller who appeals downgrades and writes off patient balances |
| Medical billing background, no dental          | Long ramp; attachments and plan design missed                   |
| Employed by the PC                             | Cost allocation and CPOD confusion                              |
| Compensation tied to collections               | Pressure on coding judgment                                     |
| No escalation path to the dentist              | Concerns go unraised, then external                             |
| No coverage plan                               | Two weeks of vacation becomes two weeks of aging AR             |
| No checklists                                  | Ad hoc process that doesn't survive turnover                    |

## Sources

1. ADA, [Dental plans: coordination of benefits](https://www.ada.org/resources/practice/dental-insurance/ada-guidance-on-coordination-of-benefits).