In house billing vs outsourced dental billing
Billing is one of those decisions that affects your cashflow every week, but it is rarely anyone’s favourite job. Most practice owners end up choosing between keeping billing fully in-house, outsourcing it, or running a mix where the team handles some parts and a remote service takes the rest. There is no single right answer. It depends on your staffing, how steady your front desk cover is, and the types of plans you deal with day to day. In this article, “dental billing” means non-clinical admin work: insurance claim submission and follow up (chasing responses and fixing rejections), patient balance follow up (statements and calls), insurance verification (checking eligibility and coverage before the visit), and recare calls to help patients stay on track with planned care.
What counts as “billing” in a dental practice (so you compare like for like)
Get clear on the exact jobs you mean, because “billing” often includes extra front desk tasks that change the comparison.
Before you compare in-house vs outsourced, it helps to agree on what “billing” includes in your practice. Different teams use the word to mean different things. If you do not pin this down, you can end up comparing a full admin role with a narrow set of billing tasks, and the decision gets muddier than it needs to be.
Here are the four billing-related areas most practices are talking about:
Insurance billing is claim submission and follow up. It includes sending the claim, then working anything that comes back: rejections, denials, missing information requests, and payment delays.
Patient billing support is communication and follow up on patient balances. That might mean sending statements, making calls, answering questions about a balance, and keeping notes so the next person can pick up the thread without starting over.
Insurance verification is eligibility and coverage checks before the visit. In plain terms, it is confirming the plan is active and understanding what it is likely to cover, so you can set expectations and reduce surprises later.
Recare calls are follow ups for planned care. This is the practical “nudge and organise” work that helps patients return to complete treatment or attend routine care, without it falling through the cracks.
These tasks sit alongside other front desk duties like scheduling, check-in and check-out, taking payments at the desk, and general patient queries. They overlap in the day, but they are not the same thing. A common problem is expecting one person to do all of it, all the time, while also staying patient-facing and calm. In my experience, that is where billing follow up slips first.
It is also worth being specific about what “follow up” means, because it is not a one-off task. Follow up is checking claim status, responding to payer requests, and correcting and resubmitting when needed. The same applies to patient balances. You do not send one statement and call it done. You track responses, answer questions, and keep moving the account forward.
If you are making a decision, a sensible first step is to list which of these areas you want covered, and which tasks must stay at the practice because they are tied to the day’s appointments. That one small step usually makes the in-house vs outsourced comparison much clearer.
Daily workload differences: what stays on your team either way
Picture a normal day and where billing jobs fit around patients, phones, and follow ups
The biggest difference is not what the tasks are. It is when they get done, and what they interrupt.
With in-house billing, the same people often have to switch modes all day. They might be checking a claim status, then the phone rings. A patient walks up to the desk. A clinician asks for an estimate. Then they are back to chasing an unpaid claim or calling a patient about a balance. That stop-start pattern is normal, but it is also where follow up slips, because it is hard to stay focused when you are patient-facing.
Outsourcing changes how the work lands. The detailed follow up work can sit off-site, so your front desk is not trying to do it in the gaps. But your practice team still has touchpoints every day. You still need to supply information, answer questions, and handle the in-practice conversations that can only happen at the desk.
A few common daily touchpoints come up either way:
Missing clinical notes or attachments. A payer might ask for supporting documentation, or a claim might reject because something was not included. Attachments usually mean items like x-rays or narratives that support the procedure. The billing person can request it, but someone at the practice has to provide it.
Eligibility questions. Eligibility is simply whether the plan is active, and what it is likely to cover. If something looks off, you may need the patient to confirm details, or you may need a quick decision on whether to proceed and how to explain it.
Patient questions about balances. Even if statements and follow up are handled elsewhere, patients still ask at check-in and check-out. They may want a plain explanation of what the balance is for, or why insurance paid less than expected. Your team needs a clear, consistent way to answer without guessing.
Payer letters and requests. Some payers still send letters that arrive at the practice. Those need to be opened, logged, and shared quickly. If they sit in a tray for days, follow up slows down no matter who is doing the billing work.
If you keep billing in-house, a practical tip is to protect blocks of uninterrupted time. Even 30-60 minutes where phones are covered by someone else can make claim and account follow up much more consistent. If you outsource, set expectations internally that the desk will still need to respond to questions and provide documents promptly, otherwise the off-site team is stuck waiting.
Some practices prefer in-house visibility, because the person doing the work is right there and can answer in the moment. Others prefer protecting front desk time, so patient-facing work does not compete with collections and claim chasing. Neither approach is automatically better. The better fit is usually the one that matches how your day actually runs.
Continuity and coverage: holidays, turnover, and ‘single point of failure’ risk
What matters is what happens when the usual person is off, leaves, or gets pulled into other priorities
Billing work is repetitive, but it is not interchangeable. The details sit in places like payer rules, claim notes, and the history of what has already been tried. Continuity is really about whether that context survives normal disruption.
With in-house billing, the most common risk is that key knowledge lives in one person’s head. They know which payers always ask for extra information, which patients need a careful explanation, and which older balances are still worth pursuing. That is useful day to day. It can also become a single point of failure if they are off sick, on holiday, or leaving.
Absence usually creates a backlog. Claims follow up and patient balance calls are the first things to slide because patients at the desk feel more urgent. Then you are not just catching up, you are picking up issues that have aged. A simple example is a claim deadline. Not all payers are the same, but many have time limits for resubmitting or appealing, and those dates do not pause because your biller is away.
Training time is the other in-house continuity cost. Even with a good hire, it takes time to learn your office habits, how you want notes written, and how your clinicians prefer to be asked for documentation. If you do not have a second person who can step in, you are betting on one role staying stable all year.
With outsourced dental billing, the continuity risk shifts. You are less exposed to one person being out, but you are more dependent on the quality of the handover and the written record. If claim status notes are thin, or if patient balance follow up is not documented clearly, it is hard for anyone to pick up the thread quickly.
You also need a clean way for updates to be shared with the practice. Billing touches the front desk, the clinical team, and sometimes the owner. If updates come in five different ways, things get missed. If they come in one agreed route, they land better. This is not about a fancy system. It is about consistent documentation and a predictable rhythm for questions and responses.
Either way, it helps to be clear on what counts as urgent. An urgent issue might be a claim rejection that needs a same-day fix to avoid delays, or a patient who is upset and needs a quick, accurate explanation. You want a simple escalation path for those moments so they do not sit in a queue.
Questions worth asking, whether the work is in-house or outsourced:
- Who covers when the main person is off, and what will they actually do while covering?
- How are tasks tracked from start to finish, including follow ups and next steps?
- How are urgent issues escalated, and who has authority to make a call when something is unclear?
- Where is key information documented, like payer quirks, claim history, and what has been communicated to the patient?
- How are updates shared with the practice, and who is responsible for responding to questions and providing attachments?
A small judgement call: if you cannot confidently answer those questions today, you have a continuity gap already. That does not mean you must change your model. It means you should tighten how the work is managed and documented.
Continuity is not guaranteed by being in-house or outsourced. It depends on management basics: clear ownership, written notes, sensible tracking, and a habit of closing loops. The model just changes where the weak spots tend to show up.
Control, visibility, and communication: how you stay in the loop
Outsourcing does not have to mean handing over the steering wheel, but it does mean agreeing how updates and decisions will work.
Most owners are not worried about whether claims get submitted. They are worried about whether they will hear about problems early, and whether anyone will make a call they would not agree with.
Control is mostly practical. It comes from seeing what is in progress, what is stuck, and what needs a decision from you.
In-house visibility is usually strongest in the moment. You can ask a question at the desk and get a quick answer. You can overhear a payer call and know it happened. That matters on busy days.
The trade-off is time. The same person answering the phone, helping patients, and checking appointments often has limited time for reporting and follow through. You may get lots of quick updates, but less consistent tracking of what is still open, and why.
Outsourced visibility works differently. You do not get desk-side answers, so staying in the loop depends on agreed check-ins, shared task lists, and clear ownership of decisions. If those are not set, it can feel like work disappears into a black box.
A shared task list is simply a running view of what is being worked, the next step, and who is waiting on whom. It is not about fancy reporting. It is about making sure you can look at a stuck claim and see what has been tried and what is needed next.
Ownership is the other piece. Someone needs to own the next step on each item, even if that next step is “practice to send narrative” or “owner to approve write-off”. Without that, tasks drift and everyone assumes someone else is handling it.
To keep control in either model, define boundaries in writing. Billing is full of judgement calls, so decide ahead of time what the billing team can decide, and what needs practice approval.
Common examples that should be clearly owned by the practice policy include:
- Write-offs (agreeing not to pursue a balance). This is a financial decision, not an admin one.
- Payment plans (how long, how much, and what happens if a payment is missed).
- Disputed balances (when a patient challenges the charge or says they were told something different).
On the other hand, many day-to-day decisions can sit with the billing team if you have agreed the rules. For example, whether to re-submit a claim with missing attachments once the practice provides them, or when to follow up again with a payer, or how to document a claim note so the next person can pick it up.
Communication expectations are worth stating plainly. If you do not, you will get frustration on both sides.
Start with response times. Not every question is urgent, but some are. Agree what “same day” means for urgent items, and what is acceptable for routine ones. Also agree what counts as urgent, such as a time-sensitive appeal, a claim rejection that blocks payment, or an upset patient who needs a clear answer before their next visit.
Next, agree preferred channels. Pick one main route for non-urgent questions and attachments, and one route for urgent escalations. The key is consistency, not the channel itself.
Finally, be clear about what information must come from the practice, because billing cannot guess it. Typical examples include:
- Supporting documentation when a payer asks for it, such as clinical narratives or notes from the treating clinician. Billing can request it and submit it, but the practice has to provide the source information.
- Updates that affect patient billing, such as a decision to waive a fee, redo work, or adjust a charge.
- Patient communication preferences and any known sensitivities, so follow up is firm but appropriate.
One small judgement call: if you want control, do not measure it by how often you can interrupt someone for an answer. Measure it by whether you can quickly see what is owed, what is pending with payers, what is pending with patients, and what needs a decision from you this week.
Cost comparison: predictability, hidden costs, and what owners often miss
A simple way to weigh costs is to list the work you need done, then look at both the obvious spend and the time it quietly pulls from the practice.
Cost is rarely just a line on a spreadsheet. Billing touches people, processes, and timing. If you want a fair comparison, start by being clear about scope. Insurance billing usually means claim submission and follow up. Patient billing is communication and follow up on patient balances. Insurance verification is checking eligibility and cover before treatment. Recare calls support follow ups to help patients complete planned care.
In-house direct costs are the easiest to see. Wages are the headline, but they are not the whole picture. You also have employer costs, training time, and the reality that busy weeks create overtime. Then there is coverage during absence. Holidays, sickness, parental leave, and turnover all create gaps, and billing is the kind of work that stacks up fast if nobody is working the queue.
In-house indirect costs are where many owners get surprised. If front desk time is pulled into claims and patient balances, something else gives. Phone calls go unanswered, check-in slows, and the diary gets less attention. That opportunity cost is real, even if it never shows up as a bill. Delays also tend to create extra follow up later. A claim left too long often needs more back and forth to untangle, and a patient balance that is not addressed early can turn into more uncomfortable conversations.
With outsourcing, the cost shape is often more predictable month to month, because you are paying for an agreed scope rather than absorbing staffing swings. But it depends on what you include. A practice that only outsources insurance billing is not comparing like for like with a practice that also includes patient billing support, verification, and recare calls. Predictable does not mean cheaper. It means the spend is usually easier to plan around when the scope is stable.
There can be hidden costs on both sides, but they are not automatic. One common source is rework from incomplete information. If claim details, narratives, or notes are missing, someone has to chase them down and resubmit. Another is the time spent answering payer requests. A payer is an insurer. They may ask for extra documentation or clarification, and the practice may need to supply source information even if the billing work is handled elsewhere.
Outsourcing also has a management overhead. Someone at the practice still needs to answer questions, make decisions on write-offs or disputed balances, and keep policies clear. That is normal. The difference is that you are managing a relationship and a workflow, rather than managing rota gaps and training day to day.
The most useful comparison is done on the same service levels. Match the scope, the expected turnaround, and the handoffs. For example, who is responsible for calling patients about balances, and how many contact attempts are expected before it comes back to the practice? Who gathers documentation, and who submits it? If those details are not aligned, the cost comparison will be misleading.
One small judgement call: if you are unsure, price out the work in chunks rather than as “billing”. Separate insurance claims follow up, patient balances, verification, and recare. You will see quickly which parts are consuming staff attention, and which parts must stay in-house because they depend on clinical or chairside information.
Quality and compliance considerations: accuracy, documentation, and patient experience
Where things usually go wrong, and what keeps standards steady day to day
Most owners worry about the same things in both models. Claim errors. Slow back and forth with insurers. And patients feeling chased or confused when balances are followed up. The basics that prevent those issues are not glamorous, but they work: clear documentation, consistent processes, and timely follow up.
In-house teams often win on context. They can quickly check details with the front desk or clinical team and fix small gaps before a claim goes out. Outsourced teams often win on repeatable process. The work is less likely to get pushed aside when reception is busy, because it sits in a dedicated queue. Either way, quality tends to track the same drivers: what information is captured, how consistently it is captured, and whether follow up happens on time.
The most common failure point is missing information. That can be a simple detail like a date, a patient plan note, or the right supporting document. Another is inconsistent notes when attachments are needed. Attachments are extra documents an insurer requests to review a claim. If notes are vague or vary by clinician, the billing person ends up guessing, chasing, or sending something that does not answer the question properly.
Slow responses to payer requests are another predictable trip hazard. A payer is the insurer. They may ask for clarification or documents, and they usually expect a response within a set window. If those requests sit in an inbox, or get forwarded without clear ownership, you can end up with delays or denials that take longer to unwind later. This is true whether the work is in-house or outsourced. What matters is having a routine for checking requests and a named person responsible for getting what is needed from the practice.
Patient communication is its own quality topic. When you follow up on balances, tone matters. So does clarity. Patients should understand what the balance relates to, what options they have, and what happens next if they do nothing. Consistency matters too. If one person is empathetic and clear, but another is abrupt or vague, patients feel the difference. That can create extra calls back to reception, and more time spent calming situations down.
Whether follow up is handled in-house or by an outsourced billing partner, set expectations up front. Agree on the words you do and do not want used, how many contact attempts are made, and when something should be escalated back to the practice. If you do not define this, people will fill the gaps with their own style.
Privacy and access should be handled deliberately in both models. Keep access limited to what is needed to do the job. Align on how patient information is shared, stored, and discussed at a high level, including who can see what and how requests are verified. I cannot tell you what is legally required for your practice, but you can still run a sensible check: if someone does not need a piece of information to submit and follow up a claim, verify eligibility, or support a patient balance call, they should not be looking at it.
One small judgement call that helps: pick a few recent claims that were delayed, denied, or required extra back and forth, and trace them from start to finish. Not to blame anyone. Just to find the breakpoints. You will usually see the same patterns: a missing detail at the start, unclear notes for an attachment, or a payer request that did not get answered quickly enough. Fixing those patterns improves quality in either model.
When a hybrid approach makes sense (and what it can look like)
You can split the work so the practice keeps what needs a person on site, and outsources the parts that mainly need consistent follow up.
A hybrid setup is often the middle ground when you do not want to fully outsource billing, but you also do not want the front desk buried in phone calls, portals, and ageing reports. It can work well when your in-practice team is strong with patients face to face, but the back-and-forth with insurers keeps slipping because the day gets interrupted.
What this looks like in real life is usually a simple split by queue. A queue is just a named bucket of work with an owner and a routine. If you cannot point to who owns each queue, hybrids get messy fast.
Here are a few common hybrids that match how most practices already operate:
1) Outsource insurance verification and claim follow up, keep in-practice payments and face-to-face questions.
Verification is checking eligibility and coverage before treatment. Claim follow up is chasing the insurer after submission when something is pending, delayed, or denied. In this model, your team still collects at time of service and handles the immediate patient conversation at the desk, but the outsourced team owns the insurer-facing work that needs persistence and documentation.
2) Outsource patient balance follow up while the front desk focuses on visits.
Patient billing support is the calls, emails, and letters that explain a balance and ask for payment, plus documenting outcomes and next steps. Your reception team keeps the in-person queries and takes payments when patients are in the practice. The outsourced team owns follow up on overdue balances so it does not get postponed when the day runs late.
3) Outsource recare calls while the practice manages scheduling.
Recare calls support patient follow ups and completion of planned care. The outsourced team can handle outreach and capture responses. The practice then books the appointment, because scheduling is tightly tied to diaries, clinician preferences, and same-day changes.
Some things must stay in the practice. Collecting at time of service is one. In-person conversations are another, especially when a patient is upset or confused and needs someone who can see the account and respond in the moment. Final policy decisions also need to sit with the owner or manager, like how you handle payment plans, when you send an account to collections (if you do), or what counts as a write-off in your practice.
The key to making a hybrid work is clear handoffs and clear ownership. Decide who owns each queue, including claims, appeals, patient balances, verification, and recare. Appeals are when you challenge a denial with additional information or a formal response. Even if an outsourced team does the work, the practice still needs to know what information is required and who is responsible for getting it.
A practical way to set this up is to agree two things for each queue: what “done” means and what triggers an escalation back to the practice. For example, a claim might be “done” when it is paid or formally denied with next steps documented. An escalation might be any request for clinical notes or an attachment the practice must provide.
One small judgement call that helps: pick one area that is currently dropping balls, and start there. If verification issues are causing treatment day surprises, start with insurance verification. If money is getting stuck after insurance processes, start with claim follow up. If balances are ageing because nobody has time to chase, start with patient balance follow up. Add the next piece only once the first handoff feels boring and repeatable.
Decision checklist: questions to answer before you choose
Use these questions to guide a short, honest discussion about what is breaking, what you can realistically cover, and what you want to keep close to the practice.
This choice is rarely about what is “best” in general. It is usually about where the work is currently slipping, and what you can support week to week without burning out your team or letting money sit unresolved.
A practical way to run this is to take 20 minutes in a meeting, answer the questions below, then circle the two areas you most want to stabilise first. One small judgement call that helps: do not try to fix everything at once. Pick the queue that is causing the most daily disruption.
Workload and slippage
- Which tasks are slipping right now: claims follow up, insurance verification, patient balance follow up, or recare calls?
- What is the pattern: certain days, certain team members, or whenever the diary runs late?
- What tends to get dropped first when the front desk is busy?
- Do you have clear “ownership” today, or does the work sit in a shared inbox until someone has time?
Staffing, training time, and coverage
- Do you have stable coverage for billing tasks, or is it constantly being pulled into chairside support and reception?
- Do you have time to train and retrain, or are you relying on one person who “just knows” how it works?
- If you hired tomorrow, do you have a written process for claims follow up, verification, and patient balances?
Risk tolerance for absences and turnover
- What happens when the billing person is off sick or on holiday? Who covers, and what stops moving?
- If someone leaves, how quickly can you rebuild the routine without ageing getting worse?
- Which risk bothers you more: gaps in continuity, or having part of the work handled off-site?
Desired control and what must stay in-house
- What do you want to stay in the practice no matter what? For many practices, that includes collecting at time of service and handling in-person conversations.
- Are you comfortable delegating insurer-facing persistence work like claim follow up, where the job is documentation, calls, and portal messages?
- Who makes the final call on write-offs, payment plans, or whether an account is escalated? If you do not know yet, decide that first.
Communication and reporting
- How often do you want updates: weekly, fortnightly, monthly, or only when something needs a decision?
- What reports do you actually use in real life? If you never look at a report, it should not drive the setup.
- What do you need to see at a glance: claim status, denials needing attachments, ageing by payer, or patient balances over a threshold?
Scope clarity and patient-facing conversations
- What is included, what is excluded, and what is the handoff back to the practice?
- Who speaks to patients about money, and in what situations? Phone follow up on balances is different from an in-person conversation at the desk.
- What counts as “done” for each queue? For example, a claim is done when it is paid or formally denied with the next step documented.
- What triggers an escalation to you? Common triggers are requests for clinical notes, missing attachments, or a patient complaint that needs a real-time response.
If you can answer most of these without guessing, you are in a good place to choose in-house, outsourced, or a hybrid split. If you cannot, that is also useful information. It usually means the next step is to define ownership and “done” for each queue before you change who does the work.
FAQ
Words from the experts
We often see the same pattern when practices compare in-house billing with outsourced support: the day-to-day work looks manageable until the queue grows, someone is off, and follow-up slips. A common problem is that claim follow up gets pushed aside because the front desk is juggling too many priorities, so we suggest a simple habit: check the aging report weekly and decide what gets worked first.
If your priority is control and quick hallway decisions, in-house can be the better fit, as long as you have steady coverage and someone owns the process. If your priority is continuity and predictable throughput when staff changes or the desk gets busy, outsourced billing usually makes more sense for the parts that are repetitive and time-sensitive, while you keep the patient-facing decisions in the practice.