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4.4.08 Issue #317 Forward This Newsletter To A Colleague

Belle DuCharme CDPMA
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Preparing for the Predictable Storm of Insurance Processing

In the story The Wizard of Oz, Dorothy is picked up by a tornado and deposited safe and sound somewhere over the rainbow. Not so on the night of Friday, March 14th, when the OMNI Hotel and World Conference Center housing the exhibitor booths for the Hinman Dental Meeting in Atlanta, Georgia, were slammed by a Category 2 tornado pushing winds of 130 miles an hour. The devastation was in the millions of dollars and several people were injured in the neighboring area.

When the storm passed, we tried to make sense of it all and one thing was certain: There wasn’t any warning of the severity of the approaching storm. It is difficult to predict natural events like tornados.

What we can do is to protect ourselves from the predictable by preparing for it. Although it is not life-threatening like a tornado (but still stress-producing), you can predict that patients with dental insurance will question diagnosed treatment and scrutinize the payable benefit like crime scene investigators. Prepare for the storm by doing the following things before a patient arrives for an appointment:

Verify patient information and eligibility by insurance website, phone or fax:

  • Subscriber name
  • Patient name
  • Subscriber date of birth/patient date of birth
  • Subscriber identification number or social security number (whichever is applicable)
  • Employer group number and division number
  • Employer name and address
  • Eligibility date and any treatment waiting period

Verify insurance plan coverage:

  • Deductibles
  • Yearly Maximums/amount left for year—very important at end of year
  • Coverage and percentages for preventive, basic, major (perio, endo, ortho, implants)
  • Frequency limitations for x-rays, prophy, fluoride, periodontal services, anti-microbial applications, crown and bridge, orthodontics, etc.
  • Prior extraction limitations
  • Alternate benefit coverage (coverage for fixed bridge would be applied to implant restoration)
  • Anticipate what codes will be used to maximize the benefits available on the plan

Being prepared with a scripted response will help you communicate confidently.
The following dialogues are examples of scripted responses.

Question: “I don’t want anything done unless my insurance pays for it. What will my insurance cover?”

Answer: “I understand how you feel. You want a benefit from the policy that you have paid for. According to the benefits listed on this document I received from the insurance company, this procedure is a covered benefit. It must still meet the qualifications for coverage under your policy, though, which is why we have taken the necessary x-rays and photos of your teeth. You have not paid the deductible of $50.00 this year, so that will be subtracted from the total benefit. The policy states that this procedure is covered at 50%. The total cost for the procedure is $850.00. Your policy is estimated to pay 50% of $850.00 which is $425.00 minus your yearly deductible of $50.00. Your estimated co-payment is $475.00.Your plan will pay an estimated $375.00.”

Question: “Why doesn’t the insurance pay more?”

Answer: “This policy was purchased by your employer based on what the company can afford to pay. The insurance company has put a limit on what they want to pay out for major services. The crown is a major service. The deductible is subtracted yearly from procedures that are subject to a deductible. Crowns are subject to the deductible. That is why it is wise to have any other diagnosed treatment completed that is subject to the deductible before the end of the year. This policy has a maximum payout of $1,500.00 per calendar year for eligible benefits. Whatever is not used is not carried over to the next year. You lose it. It is wise to use this valuable benefit even though there is out-of-pocket expense to you.”

Question: “I get better coverage if I go to a dentist on my plan. I have to leave your office and I don’t want to.”

Answer: “Thank you. We appreciate you and your family and we don’t want you to leave either. You should consider that before making your final decision. The trust you have in us and the comfort you and your family feel when you are here is important and you may not find that in another practice. I know that costs are important to you as they are to us all. Your insurance is good here and there may not be that much difference in the out-of-pocket costs as you think. For instance, according to your plan, your professional cleanings and examinations will still be covered at 100% twice a year.

The difference in the dental benefit is $130.00 paid to us versus $85.00 that would be paid to a plan provider. You still pay us nothing. We can research the difference for other procedures that you will need prior to you having anything performed. If you decide to go to another provider and are not happy there, you are always welcome to return to our office.”

Want to learn more about preparing for the predictable? Call us today for information about our Advanced Training Programs for dental professionals.

For more information about McKenzie Management’s Advanced Training courses, email, call 1-877-777-6151 or visit our website at

Interested in having Belle speak to your dental society or study club? Click here.

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