Dental Insurance Reality Check
It begins innocently enough. You diagnose necessary treatment for the patient. It’s consistent with your standards. You recommend to patients the treatment that you would advise your own family to receive. You don’t make your diagnosis based on what you perceive the patient can afford or what you think insurance will cover, rather it’s rooted firmly in appropriate standards of care and based upon what you consider to be the best course of treatment for the patient.
And then one day those standards backfire. Insurance won’t cover the crown you’ve recommended. Suddenly, the patient sitting before you is quietly questioning your integrity. It’s as if they view the insurance company as the police, and you have been busted! In other cases, the patient perceives that the staff is incompetent, reasoning that if the practice had filed the claim correctly, it would have been paid. Or perhaps the patient wants to “help everyone out,” so they take it upon themselves to research the matter and explain to your business staff how to handle it.
“The insurance representative I talked to said all you have to do is code it as an ‘XYZ’ and the insurance company will pay the claim.” If the employee handling this patient doesn’t know better, s/he may take their “advice,” thereby putting the practice in a position in which the doctor could, in fact, get busted for insurance fraud.
Dealing with insurance can be nothing short of exasperating for many practices. Patients may have excellent medical insurance that covers the care they need until they are well, yet they have severely restrictive dental insurance that provides a mere $1,000 in dental benefits annually, which further fuels the perception that dental care is not all that important. Worse yet, the patient may not be allowed to use the dental benefit as s/he chooses. The insurance company may dictate percentages, perhaps paying 50% on crowns, 20% on amalgams, and requiring the patient to meet an annual deductible.
How do you tell the patient that his/her dental coverage is horrible? How do you explain that the company’s understanding of dental care is stuck somewhere in the mid-twentieth century, completely out of touch with modern dental procedures and standards? How do you communicate to the patient that they have a choice: their dental insurance or their teeth - what’s it going to be?
It all begins with managing patient expectations. And that begins with education. “But Sally, isn’t it the patient’s responsibility to know and understand what their dental insurance covers?” Yes, of course it is. But if you and your team are not proactive in educating patients, you will be far more likely to find yourself in situations like those above where the staff and even the doctor have to defend or justify treatment recommendations, or they have to tap dance around awkward and potentially illegal requests. Better to be proactive. It’s important for every patient to understand that dental insurance is severely limited, and the insurance company is not the dental expert.
Your financial coordinator should sit down with the patient and review what’s covered in their dental plan according to a prepared script in which the situation and options are clearly articulated and the coordinator is ready with the answers to those frequently asked patient questions and concerns. Discuss the calendar year cap, deductibles, co-pays, coverage for preventive care, etc. The greatest benefit of a script is that you know precisely how to respond and you are well prepared. Doctor and team can better manage the messages to ensure they are clear and professional. Specifically, patients need to understand that they have a limited dental benefit; however, that doesn’t mean that you, the dentist, will ignore infections of the mouth. One of the most common areas of insurance frustration is the lack of understanding of periodontal disease.
Insurance companies commonly pay for two professional cleanings a year. The patient believes this is all that they need because additional prophys are paid out of pocket . Consequently, many dental practices do not have active “interceptive periodontal programs” for fear of losing patients. These offices let the insurance companies dictate treatment to the detriment of the patient’s dental health. However, if a patient had an infection or disease in their heart or lungs or any other part of their body, they would not expect their physician to ignore it because insurance wasn’t expected to cover the treatment. The same should hold true for their dentist.
For more information on this topic, visit my blog: The Lighter Side
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