11.21.14 Issue #663 info@mckenziemgmt.com 1-877-777-6151 Forward This Newsletter

Nancy Caudill
Senior Consultant
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Estimating Your Patientsí Portions
By Nancy Caudill, Senior Consultant

Do some of you remember the days before insurance? Patients simply “paid” for their services. There were no terms such as out-of-pocket, co-pay, deductible, maximum, not allowed, not covered, missing tooth clause, waiting periods and all the other terms that your Business Coordinator has to deal with now. It would appear that you need to be an “insurance expert” to simply ask the patient for the anticipated portion. And even then, with all the technology and tools that your Business Coordinator has, it is still an educated guess. This article is a brief overview of one way to approach the patient regarding their benefits.

Where Does Benefit Information Come From?
1. Outside software programs (often available for a fee) provide some information based on the patient’s ID #
2. Contacting the insurance company directly through their website and obtaining the information using the patient’s ID #
3. Calling the insurance company and either speaking with a representative directly or requesting a fax containing information based on the patient’s ID #
4. Entering the information directly into your practice software, if it is a PPO plan that you are participating with. However, this will not indicate whether the patient is eligible at the time of service, only information regarding the benefits for that particular plan.
5. Over time, building the coverage book in your software program for plans as payments are posted.

How Accurate is the Information?
There are no guarantees in this business when it comes to obtaining benefit information. What affects the accuracy of the information?

1. Who you speak with at the insurance company. You may get a different response from two different agents at the same company for the same plan!
2. The plan benefits change and your practice is not aware of the changes.
3. The patient is no longer eligible due to non-payment of dental premiums, changes in employment, waiting periods, etc.
4. How the information is obtained or interpreted by your Business Coordinator.

Honestly, it seems that patients think your computer is somehow connected to their dental plan. They assume you have “instant access” to accurate information and can tell them exactly how much their plan is going to pay. We only wish it was that easy, right?

Discussing Benefits with Your Patient
It is the responsibility of the patient to understand his or her benefits. We sure would like to think so…then they could tell US how much their insurance will pay! But this is not reality. If you work at the front desk of a dental practice for a few days, you will quickly see that patients have no clue about their insurance benefits. Many times they don’t know the difference between their medical and their dental plan.

I always start by telling the patient with a sincere and sympathetic smile on my face: “Mrs. Jones, we don't know how much your insurance is going to pay. Based on our experience, I can estimate that your portion will be about $125. (Always “guestimate” on the high side). After we hear from your insurance company, we will contact you if there is any difference. How does that sound?”

Often I get a glare from front office staff when I suggest they admit that they don't know how much the insurance is going to pay. Some want to project to the patient that they are “insurance experts”. We find that patients will not hold you as responsible if you are honest and tell them that you don't know – because we don't know! The more we project to know, the more the patient expects us to know. 

When estimating the patient’s portion, it’s important to round off so it doesn’t appear to be precise. I have not worked with a dentist yet who prefers to send a statement and try to collect the unpaid portion from the patient opposed to sending a refund check.

Are there situations where your Business Coordinator knows exactly what the patient’s plan will pay barring no unforeseen circumstances? Of course. And it is fine to request the exact amount from the patient. The goal in collecting “patient portions” is to avoid having to send a statement after the fact and then manage patient calls explaining why the insurance didn’t pay what was expected.

Ideally, your patients are so informed and "sold" on their treatment recommendations that they want the treatment regardless of out-of-pocket cost, and they understand your office team will do everything in their power to maximize the benefits. “Mrs. Jones, we will do our best to maximize your benefits, but please understand that we have no control over how they will handle your claim.” Maybe a simple way of stating this is to “under-promise and over-deliver”. I have never seen a patient who was upset that the insurance company paid more than anticipated, just like they are not upset when you didn’t need to perform a buildup, thereby reducing the fee they were initially quoted.

Avoid being an insurance benefits “expert”. Patients just want to know how much you want them to pay at their appointment. Keep it simple!

If you would like more information on how McKenzie's Consulting Coaching Programs can help you implement proven strategies, email info@mckenziemgmt.com

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