How MediClaim Works Made Enterprise Medical Billing Affordable for Dental Practices

MediClaim Works exists to give dental practices real access to enterprise-level medical billing, without the runaround. As the organization’s owner, Dondra Edwards takes that mission personally. Dental practices typically use fewer than 15 of the roughly 70,000 CPT codes used across medicine, a tiny slice of the billing world that made it easy for them to get lost inside solutions built for the whole industry. That disconnect is what led Edwards to build MediClaim Works in the first place, so dental practices wouldn’t get lost in a system built for someone else.

For years, Edwards referred dental clients to an outside vendor for medical billing, with little control over how those clients were treated once they got there. Dental practices, using such a narrow set of codes, often became just another account among thousands. “Dental practices kind of get lost in the shuffle of medical billing,” she said.

That arrangement stopped working when the vendor was hit by a major disruption in the healthcare billing industry. It also exposed a bigger problem. Enterprise medical billing solutions are typically built and priced for the full scope of medicine, not for a specialty that only needs a fraction of it. For a solo or small dental practice, such a huge investment rarely made sense. Edwards saw an opening to create something better, and that search led her to Inovalon.

The mismatch went deeper than pricing. Dental practice management systems like Dentrix, Open Dental, and Denticon can transmit a medical claim, but they’re built for cross-coding, not for the modifiers and qualifiers a clean medical claim needs. A simple procedure like a surgical extraction might get through, but for practices doing bone grafting, trauma cases, implants, or full mouth reconstruction, those systems can’t get the claim paid.

Inovalon’s platform is built to scale to an organization of any size, and Edwards used that flexibility to build something new for a niche market. Instead of every dental practice standing up its own account, MediClaim Works became the customer and built a shared model that lets an entire network of practices run off one platform together. “MediClaim Works was created to be that intermediary for the dental industry, so they could have access at an affordable price to an enterprise solution like Inovalon,” Edwards said.

The model is straightforward. MediClaim Works holds the parent account with the full range of Inovalon’s enterprise capabilities, and individual dental practices pay a subscription to use it. “We have all the Inovalon bells and whistles, and then our clients pay a subscription and get access to all of it at a fraction of the cost,” Edwards said. It’s a model built for a market where a single practice files a relatively small number of claims on its own, so pooling access lets a whole network run on enterprise-grade tools without needing enterprise-scale volume individually.

MediClaim Works trains every practice on two connected tools, Inovalon’s Claims Management Pro™ and Eligibility Verification Starter™, from day one. “If you’ve ever used an Excel spreadsheet, you’re going to be very successful in navigating Claims Management Pro.”

That simplicity matters because of who’s actually doing the billing. In a small dental practice, the person entering claims might also be the office manager, the front desk lead, or a dental assistant, already juggling two or three other roles. Edwards has built rules into the platform that skip fields a practice already knows the answer to, like confirming a signature is on file, along with payer-specific logic that catches mistakes before they cause a denial. Those small shortcuts save minutes on every claim. For Edwards, that adds up to something more valuable than speed alone – more time her clients’ staff can spend with patients instead of fighting the software.

Before a practice ever files a claim, MediClaim Works puts them through a credentialing process, confirming taxonomy codes, clearing up inconsistencies, and training the team on exactly what documentation needs to accompany a claim, since missing paperwork is one of the most common reasons claims get denied.

Edwards has seen what happens when that step gets skipped. She recently met with a practice that had tried medical billing with two other companies without success. Neither had credentialed the practice, and both had, in the client’s words, just taught the software without teaching how to actually implement medical billing.

MediClaim Works trains every role in the process, the front desk person capturing insurance information, the clinical team, the provider, the biller, and the treatment coordinator, so nothing falls through the cracks. “One without the other, you’re not going to be successful in medical billing,” Edwards said.

“Our goal is to train the client to where they don’t necessarily need us anymore,” Edwards said. The company recently began offering full billing services for practices without the staff to do it themselves, but even then, practices keep full visibility into their own claims, since MediClaim Works files under the practice’s own license and tax ID, a level of transparency Edwards says most billing companies don’t offer.

That same model has made it possible for dental practices to expand into sleep medicine, a growing specialty that’s often a natural next step for experienced dentists. “It’s a stepping stone for a lot of providers,” Edwards said. Dentists who have spent years doing physically demanding work, like root canals and oral surgery, can shift into sleep medicine, which is far easier on the body while keeping them active in the field they love. For many, it’s a way to keep doing the work that drew them to dentistry in the first place, helping patients, without the physical toll that comes with years of general practice.

Billing for sleep medicine is simpler, too. It typically involves only three to four CPT codes, and much of the required documentation comes from the referring physician, which keeps claims clean and payment quick. “Most of our clients are getting paid in three to four days,” Edwards said.

When dental practices add medical billing, revenue tends to follow, but Edwards is careful to point out that it isn’t the goal. “They’ll definitely see an increase in revenue, but that’s not the reason to get into medical billing. It’s just a byproduct,” she said. “The real reason is to give your patients another resource to pay for the care they need, care they might not otherwise be able to afford.”

That distinction makes sense once you see how little dental insurance actually covers. “Dental insurance only gives you $1,500, sometimes $1,200, a year for your care,” Edwards said, and something as routine as a comprehensive exam can draw from the same allowance as a hygiene visit. Once a patient hits that ceiling, or needs a procedure their plan won’t cover at all, they’re often left paying out of pocket or walking away from care they need. “It was creating a situation where patients weren’t getting the treatment they needed because they couldn’t afford it,” Edwards explained. “Medical insurance opens the door for that opportunity.” Procedures billed under medical typically reimburse at a higher rate than the same care billed under dental, too. Edwards has seen firsthand how that changes outcomes, as case acceptance rises once patients have another way to cover their care.

That patient-first approach also shapes who Mediclaim Works chooses to work with. Edwards has turned away prospective clients who were chasing revenue instead of better care for their patients. “We know from experience that when providers get into medical billing only to increase revenue, they lose sight of the real reason, which is patient care,” she said.

MediClaim Works is also looking forward to Inovalon’s upcoming prior authorization solution, aimed at a problem Edwards’ clients feel today. Getting a prior authorization currently means calling a payer and waiting on hold, or logging into a separate portal for each payer. Every instance is another place to check and another number to track by hand.

Bringing that process into one system will make providers more efficient and give them the kind of detail that improves the whole claims workflow. Instead of manually tracking a prior authorization number, it will live in the system automatically and flow right into the claim when it’s needed.

The size of a dental practice shouldn’t determine whether they matter, and practices shouldn’t have to choose between going without or overpaying for tools built for someone else’s scale. That’s the gap MediClaim Works is able to close with Inovalon. By becoming the enterprise customer so its clients don’t have to, MediClaim Works has given dental practices a path into medical billing that’s fast, affordable, and built around patient care, with even more efficiency on the way as its partnership with Inovalon continues to grow. At the center of it all are patients who can finally say yes to the care they need.