Scripting for Periodontal Maintenance
As Business Coordinators/Financial/Insurance Coordinators we are constantly asked questions in regards to billing dental insurance for preventive teeth cleanings (prophylaxis) versus periodontal maintenance. Clinicians know the difference between the two services and are relied upon to relay the information to the patient. Often the patient’s next response is “Does my insurance pay for it?” At this point, the patient is transitioned to the front desk for answers and for scheduling. Before the patient is transferred to the desk, the clinical team needs to make sure that the education process is complete and that the patient understands the consequences of not complying with recommended treatment protocols. The uninformed patient that has had scaling and root planing often thinks they can go back to regular cleanings.
Unfortunately, patients with a low trust of dentists or with the belief system of the eventuality of losing their teeth look to the insurance company to validate whether their care is “necessary” or not. Being prepared by anticipating this question is your best defense. Know enough about the differences between a preventive service such as a “regular” cleaning and a therapy treatment as in the periodontal maintenance visit. To be convincing to motivate the patient is important as patients tend to ask for information they have already received from the clinical staff.
Some suggested scripting would be as follows:
“Mrs. Brown, I know it is important for you to have coverage for your care. I have been able to communicate with your insurance provider and have found out that the periodontal therapy maintenance visits are covered. Your contract allows an 80% payment for our fee. There is a $50.00 deductible applied to this service once a year. In other words, they will pay 80% minus 50.00. We will provide the necessary documentation of your condition along with the claim to the insurance. Each year, your plan will pay for 3 periodontal maintenance visits. Our recommendation is 4 visits, so one will be your responsibility for payment.
The early stages of periodontal disease is the best time to halt and manage its progression. Our dental hygienist uses special instruments to clean where your toothbrush and floss can not go to remove debris and toxins causing the gum disease. Losing teeth is not an option at this point. We must protect your oral health, which is essential to your overall physical health. We cannot ignore a bacterial infection simply because of insurance limitations.”
Another scripting scenario would be the following:
“Mrs. Brown, as you know, our goal is to provide excellent dental care to all of our patients, regardless of whether they have dental insurance or not. The information that I have obtained from your insurance company is that they will pay for two dental hygienic visits per year, whether they are preventive or periodontal therapy in nature. This is a plan limitation and not a judgment on the type of care that you need. According to Dr. J and Dee, our hygienist, you have a bacterial infection that needs to be treated. After the treatment, you will be placed on a maintenance program so that we can monitor your healing and bone loss. Dr. J recommends 3 periodontal maintenance visits a year for which two will be covered by your insurance company.”
Some patients don't think it is harmful to change codes or alter treatment notes in order to get more benefits from their insurance company. The patient may even report that the insurance company has instructed them to tell you to bill for another code so that they get coverage. This is the time when a three-way phone conference is in order between the business coordinator, the patient and the insurance company representative. Put on the spot like this, the representative must tell the patient that the doctor has a legal obligation to code services correctly by choosing codes which most accurately depict the treatment rendered. The plan representative may not understand the risks for the doctor in falsifying claims to gain benefits.
In order to get better benefits in the future, patients should be encouraged to communicate with their employers to increase the dental benefit coverage, or to negotiate for better coverage on specific services such as periodontal maintenance.
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