The Facts of Life About Dental Insurance (Part 3)

A real-world look at the practice of dentistry from the perspective of Dr. Clary...

I live in the real world. In fact, it says it right up there in the little italics. I know it's one thing to expect a patient to understand their dental insurance. It's a completely different thing for that to actually HAPPEN. But the better we can communicate expectations to them, the better a chance we stand in helping them become an active partner in their care.

So, what comes AFTER the examination?

This is a vital juncture in helping patients get the most out of their dental care. After the initial consultation we need to involve them in developing a plan that will optimize their systemic health. Drill, fill, patch, and paste is quickly going the way of the VCR -- you can find one here and there even if their methods are obsolete. And we cannot stop talking about the care plan after the first exam. This must become the focal point of each appoitnment. Patients need to have a clear and complete understanding of the costs involved before treatment begins.

If the treatment plan is extensive, (i.e.) involving numerous fillings, periodontal (gum) treatment, crowns, bridges, etc., we should submit the plan to the insurance carrier for predetermination of benefits. The insurance carrier will then determine what portion of the total fee they will pay based on the insurance contract. The insurance carrier is supposed to provide copies of the predetermination to both the dentist and patient, and it is important for the patient to understand that the insurance contract is an agreement between them and the insurance carrier only.  The dental office is not a party to that contract. Again, therefore, THE PATIENT is ultimately responsible to US for the entire dental bill, and the insurance carrier is responsible to them. 

In many cases, as a service to the patient, we will make arrangements that allowpatient to pay only their portion.  We may also have a variety of payment options available to make proper care a possibility.  And, if during the course of treatment, we find that additional services might be needed, we need to be open in discussing these and the additional cost.

Which brings us to a frank discussion about fees. We were trained as dentists, but need to not just think about the mouth, but the pocket. We have to manage our finances effectively if we are to maintain a healthy practice. And we should not be ashamed to discuss our fees with our patients.

They should know that most insurance plans base the amount of benefit on a chart or schedule of fees arbitrarily developed by the particular insurance carrier. This schedule of “allowable” fees can vary dramatically from one insurance carrier to another, however.  For this reason the patient may receive a lower percentage of the reimbursement level then indicated in the dental plan.  For example, if the plan states that it will pay 80% of the fee arbitrarily determined by the insurance company and not necessarily the actual fee charged by our office. If we happen to charge more for a particular service that a patient's insurance provider allows, they need to know we will bill for this difference and they will be responsible for paying us that additional amount.

Most dental insurance carriers have done a credible job managing this growing industry. However, it has been the experience of most dentists at some time that occasionally companies tell their clients that certain dental fees are “above the usual and customary” rather than telling them that their benefits are low. We also know that some carriers do not upgrade fee schedules regularly, even with the cost of living index. t’s logical, then, that there may be an attempt to shift the responsibility. Remember, since the insurance carrier is in the business to make a profit, they will do what they can to minimize payment. Essentially, patients get back only what your employer put in – minus the profit.

The fees allowed by an insurance carrier are usually based on “averages.”  They do not take into consideration the complexity of a particular case, special management considerations for the patient, cost of better quality dental materials and techniques, time spent on treatment planning, and extra services provided by a dental office at no charge such as filing treatment predeterminations and claims for the patient.  The “allowed” fees also do not take into consideration the length of time that elapses between the filing of a claim with the insurance carrier and the time that the insurance company finally sends payment to the dentist.  Dental insurance companies have also been known to “lose” claims resulting in additional payment delays.  This reduction in cash flow and associated cost of carrying accounts receivable has prompted a growing number of medical and dental offices to discontinue such services as filing insurance claims on behalf of the patient and allowing assignment of benefits directly to the dental or medical office.  Instead, they require full payment of the entire charge by the patient at the time treatment is performed.

And all that said, over the course of these three posts, despite its limitations and frequent frustrations, it must be recognized that dental insurance is indeed a true benefit to many people. It has prompted many of those individuals who have neglected their oral health in the past to at least seek initial dental care simply because they have “insurance.” It is a benefit that if not used is lost.

As dentists, we must be committed to honest, open communication.

We need to take time to talk and answer questions.

And when we hold ourselves to that level of service, we can hold at bay a lot of the headaches that go along with running a thriving practice.

The Facts of Life About Dental Insurance (Part 2)

A real-world look at the practice of dentistry from the perspective of Dr. Clary...

In my last post, I laid the groundwork for more effectively commuicating with patients about their dental insurance. As much as we may like to take an "it's-not-my-job" approach to talking about benefits, it is in our best interest to help our patients maximize the use of their dental insurance. To that end, here's more from my perspective...

Our office does not determine a given patient's dental benefits. The type of plan chosen by the employer determines program benefits. In other words, the amount a plan pays is determined by how much an employer is willing or able to pay for the plan. The insurance carrier then tailors the plan to the employer and specifies what services will be covered and what benefits will be paid to fit that premium payment.

I know, I know. I can actually HEAR you shouting at the computer screen. Sure, patients THINK DENTISTS DETERMINE THE BENEFITS. Which is just one more reason why we need to talk about these things with them.

In many cases, the office is not involved with dental plan carriers in any way. And since dental services are rendered directly to the patient, it follows that the patient is ultimately responsible for payment. The dental plan carrier is responsible to the patient. 

And here's when that comes into play: As dentists, our responsibility is to provide patients with an accurate assessment of the current dental condition and offer treatment recommendations. Our treatment recommendations, however, are not based on whether the patient has dental insurance.  Our responsibility is to provide the best possible treatment individualized for the particular situation – not the insurance carriers.

Within these parameters we can work to maximize your dental benefits. For example, we might stage treatment where dentally feasible in order to maximize benefits. We will provide the insurance carrier with the information it needs to accurately determine benefits due. As a service to our patients, we can also file insurance claim forms.  Usually there is no charge for this service. However, if the insurance carrier requests more extensive narratives or duplication of x-rays, we should feel comfortable charging for that, whether the insurance company will pay or pass it on to the patient.

We should also set the expectation up front with the patient:

In order for us to file claim forms, the patient must be responsible for providing us with all of the necessary policy and plan information at the first dental visit. In addition, they must be responsible for informing us of any change in insurance status (i.e. dual coverage with spouse’s insurance, change of insurance carrier, or change of plan features) at each subsequent appointment. Processing dental claims is an expensive and time-consuming activity for a dental office. Our efforts at controlling dental costs rely on the patient being a partner.

And for patients, being a partner means having a full understanding of their benefits. Dental practicies often have members of the staff who who are familiar with dental insurance and who may be able to answer many patient questions. But since individual plans offer special coverage and restrictions, it's unreasonable to expect the staff can provide all of the answers. Patients often need to look to their employer or benefits provider to find the answers. And it's okay to tell them that's where they need to go.

If we fail to communicate these things, we set ourselves up for dissatisfied patients. Seems trivial, but it's often a lack of clear understanding of benefits that will turn a patient against you. Being able to talk matters. And an investment in a little bit of clear communications up front can serve to save you TONS of time unravelling a situation down the road.

The Facts of Life About Dental Insurance (Part 1)

A real-world look at the practice of dentistry from the perspective of Dr. Clary...

During the past decade, dental benefits plans have become an integral part of health care planning for many families. These plans are made available to employees or members, through companies, unions, and associations, and may vary considerably from one plan to the next. Today approximately 80% of our patients have a dental benefit plan in one form or another. 

But are we, as dentists, helping those "4 out of 5" gain a clearer understanding of what this benefit actually entails? In many cases, "No". In few cases, "Hell No". The better we can help our patients UNDERSTAND what their insurance benefit is all about, the more effeciently and effectively we can operate our practice. And the smoother a practice operates, the easier it is to market.

So, to that end, here is one way of explaining dental insurance to your end users.

First of all, dental “insurance” is not insurance in the true sense. Insurance such as life, auto, and household is based on the likelihood that death, accident, fires, and theft will not occur. Dental “insurance” on the other hand, is based on the likelihood that the beneficiary will use dental services. 

Therefore the premiums paid for the dental “insurance” policy determines the amount of benefits paid. The greater the premium, the greater the benefits in dollar amounts available and/or the dental services covered. Thus, dental “insurance” was never designed to cover the total cost of all dental treatment. A better term would be “dental assistance” program.

Unfortunately, many people have an inflated view of what their dental insurance is going to pay. The insurance carriers have frequently promoted this misunderstanding themselves. This is especially true if it is a new policy.  The fact is that most policies pay 80% to 100% of preventive procedures such as exams, x-rays, and routine cleanings (dental prophylaxis), 50% to 80% of routine procedures such as regular fillings, and 0% to 50% of the more expensive and extensive types of reconstructive dentistry such as crowns, bridges, and dentures. 

In addition, many policies place age restrictions on such procedures such as fluoride treatments, and will only cover certain procedures once every so many months regardless of the actual dental need of the patient. Also, most policies have yearly deductibles in the range of $25 to $50 per person as well as yearly maximums usually in the range of $500 to $1000 per person, or occasionally a lifetime maximum. Patients also need to be aware that some policies do not cover procedures such as orthodontics, crowns, bridges, and more extensive dental cleanings or gum treatment regardless of the patient’s actual dental needs.

Basic to us, oftentimes as clear as mud to our patients. The more consistent we are in spreading the message, the more we can help our patients to effectively maximize their benefit.

In Part 2 of this series, we'll dig deeper into the benefit.