Avoid Firings at All Costs
I have a laminated copy of a check from a well-known dental insurance company (name I will not disclose) for the amount of twenty-seven thousand five hundred dollars ($27,500.00). I keep this as evidence to demonstrate to my patients that insurance companies do make errors. The check amount was supposed to be $275.00 as payment in full for a home teeth-whitening kit. The fact that the insurance company covered the whitening was impressive enough without the error in payment. After all, we have been told that insurance companies do not pay for cosmetic procedures. This is a blanket statement that needs to be qualified to say, “most insurance plans do not have benefits for cosmetic services.” We are now in the age of the “designer” dental benefit plans that defy explanation, especially the plans that cover one prophy in a calendar year. Remember that the employer draws up these plans with benefit provider based upon costs. When claims are submitted they are administered per contract not by dental necessity.
Maximizing a patient’s benefits for a calendar or contact year is not much of a challenge since the benefit years’ maximums have not gone up in thirty or more years. If you are a contracted PPO provider you will find that you can do more dentistry yet get reimbursed for less because you are subject to write-offs (if you bill out UCR fees).
Often the question is asked, “Can I charge more for a procedure than the PPO fee schedule allows?” I have spent some time researching this question and the most popular answer is NO. However there are some gray areas that need to be addressed. As I have said in other articles, “If you are going to play the PPO game then you better know the rules of reimbursement for each plan you are signed up to accept.”
You need to know if the procedure you are planning to do is covered by the plan. If not, then you can charge your UCR fee unless there is a clause in your agreement that states you must “discount your fee by 15%”. It could be anywhere from 10 to 25% but I use 15% as an example. If it is covered by the plan but the reimbursement amount is sadly low then you need to look at the costs involved in producing the item. For instance, an insurance company (I won’t disclose the name) reimburses 50% of $392.00(this is a real contract fee) for each Porcelain lab produced veneer. The lab fee is almost $200.00 for each veneer because you use the best lab and you are certain of a good result. Your UCR fee for this veneer is $1100.00 each. The PPO contract says that you must accept as payment in full the contracted fee and not charge the patient the difference. “ARGHHH,” I realize that dentist fees and lab fees differ from state to state but some insurance company fee schedules don’t.
Looking at this scenario you cannot produce the product for the amount of money you will be reimbursed. Your options are: 1. Not to offer the service and refer the contracted patient out of the office 2. Find a cheaper lab, and explain to the patient that the result may not be the best 3. Explain to the patient about the situation and say that you cannot provide Porcelain laminate Z but you can provide Porcelain laminate X for $200.00 each more because you need to use Lab Q for the best result and let the patient decide what they want to do.
Understanding “alternate benefit” rules are important to getting reimbursed. If a procedure is not a covered benefit, the patient pays out of pocket at UCR rate. Sometimes there is an alternate benefit, such as composite restorations that are often downgraded to amalgam. If you do not provide amalgam then you can upgrade to the composite fee and the patient pays the difference. Always explain to the patient that the insurance covers the cost of amalgam on posterior teeth and you are placing composite or (white fillings) instead.
Insurance billing and reimbursement is a large segment of the Advanced Training Course for Front Office Dental Employees offered by McKenzie Management. The benefit to you is that we customize your training to fit your needs. We look at whether you are a contracted PPO provider, accept PPO assignment with patient share of costs or both, and with our resources help you to achieve a higher level of success in your practice. Join us today and enrich your knowledge for a more profitable practice.
For more information on McKenzie's Advanced Training for Front Office, Office Managers or Dentists email email@example.com, call 1-877-777-6151 or visit our web-site at http://www.mckenziemgmt.com/.
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Case Study #28
Dr. Sandra Short
Dr. Sandra Short called in and expressed her concerns about the practice needing some guidance to help improve production. Not an uncommon comment from our inquirers. The culprit(s) causing the practice malady is not as easy to diagnose, however. A visit to the office is in order.
All of McKenzie Management’s consultants have lunch with the staff (no doctors) only on the first day after our arrival. It gives us an opportunity to get feedback about the doctors (yes…they will tell on you, Doctor!) It is okay, however. We need to know what is on their minds and they also need to know that we are there to support them and their ideas as well as the doctors’.
They shared with me that they were unclear as to what the doctors expected of them, and as a result, they felt that they were reprimanded for poor performance. They were not recognized for accomplishments and positive results. True or not, “perception is reality”.
As I monitored the next two days in the office, I quickly realized that there was no employee assigned to any particular task. The front office employee answered the phone, scheduled patients if they called, sent statements, entered information into the computer, and called recall patients “when she had time”, etc.
The assistants and hygienists scheduled all the appointments for the patients chairside, posted the charges chairside, called past due recall and unscheduled patients when they “had time”. They were expected to sell dentistry chairside, arrange financing and answer insurance questions. They were confused….clinical or business? Business or clinical? What hats do they wear?
Here is a list of systems that I found non-existent in Dr. Short’s office.
Not only did the office not have systems, there was no one responsible for the tasks that they were attempting to perform.
The first obvious strategy was to establish 2 specific job descriptions for the following positions:
This position was accepted by the existing front office employee. She learned that, in addition to her current tasks, she was directly responsible for the following tasks:
This position will be filled by a new employee that has experience in the dental field in order to discuss various treatment options AND someone that enjoys “dialing for dollars” and SELLING dentistry! She will be directly responsible for:
By having these job descriptions defined and assigned, there is accountability for the doctors and there is no more confusion for the staff regarding “who is doing what”.
As a dentist and the leader, it is imperative to define who is performing the various tasks in your office. How can you expect jobs to be completed when no one knows who is going to do it? When you make a blanket request such as, “I need someone to send out the lab case” during your morning meeting, who will you thank when it is done? Or, if the task isn’t performed, whom do you question? It is not fair to expect your team members to delegate tasks among themselves. However, in many offices there is that one employee that takes on all the responsibilities with no recognition because the doctor isn’t aware that she/he is doing it.
Along with a monthly statistical report, Dr. Short now has the tools that she needs to monitor the performance of her staff members and enjoy the results that this brings. Her employees will develop self-confidence and create recognition for themselves by performing these tasks as delegated. It becomes a win-win-win situation for everyone…the doctor, the staff and the patients.
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