I’ve written this article in response to numerous requests from readers and seminar attendees to talk about a common sense-based approach to handling patients’ dental insurance.
There is always a debate as to whether the dental office should accept insurance assignment or not. I am a big believer in doing whatever has been successful for you. In our office, we have chosen to accept insurance assignment. The reason for this is basically good old competition. Most of the dentists in our area do accept insurance assignment.
Patients generally have three main objections to dental treatment—time, pain, and money. I would venture to say that for many people money is the primary obstacle. For that reason, accepting insurance assignment is beneficial because the patient does not have to make such a large out-of-pocket investment to our office, and it makes our practice a better value.
Accepting insurance assignment does not affect our treatment plan for the patient. We examine and diagnose patients as if the insurance does not exist. Our suggestions for treatment are based on patients’ needs and wants. We will then work with the patient to structure a plan to make sure that they get the treatment that they need in a way that is affordable for them. We investigate the patient’s dental insurance and figure that into the total package of treatment costs and eventually the out-of-pocket expense to the patient.
When patients first call our office to make an appointment, our office manager will casually ask in her initial phone interview if they have any dental insurance. If they do have insurance, the office manager will politely ask for the insurance information so that we can verify the insurance plan and benefits prior to the patient’s appointment. This step alone is extremely important. If we are able to verify patients’ insurance before they come in, then the day they come in for their appointment is when we can actually get started with treatment, if the need arises. This also tells patients that we take their financial needs seriously, and will work with them to maximize their benefits so that they can get the dental treatment that they want.
If you ask patients what their insurance covers, I would bet that eight out of ten patients would answer, “everything.” Most patients have absolutely no idea what their dental insurance covers, that there are percentages or fee schedules involved, and that there are exclusions. This short, initial conversation about the patient’s dental insurance lets them know that while they may have insurance benefits coming to them, it certainly will not cover “everything.”
Once the office manager has the dental insurance information from the patient, she will call the insurance company to verify the patient’s benefits. The importance of this call should not be underestimated. The office manager follows the following checklist to find out more about the patient’s dental insurance:
- Subscriber name and social security number
- Insurance company name, address, and phone number, and the name of the insurance Representative to whom you spoke
- Employer name and group number
- Maximum benefits
- Calendar year or benefit year
- How much has been used to date
- Deductible amount, family deductibles, and has deductible been met
- Any waiting periods
- Missing tooth exclusions
- Date of eligibility
- Is reimbursement based on usual, customary, and reasonable (UCR) fees, or fee schedule
- Break down of benefits in percentages:
- Class I – Preventative
- Class II – Restorative
- Class III – Major
- What class are endodontics, periodontics, and oral surgery in? Are night guards, occlusal adjustments, frenectomies, bone grafts, and implants covered?
- Frequencies – Are exams, prophys, and bitewings allowed two times per calendar year or six months to the date? Is fluoride treatment covered once or twice per year and is there an age limit?
This checklist has been developed over the years in our office, and we find that it will, in a nutshell, give us a very good idea of what the patient’s insurance is going to pay. Generally speaking, once you get through to an insurance representative, you can have all this information in less than five minutes.
Unfortunately, you will occasionally get insurance clerks on the phone who really have no clue what they are talking about. Our advice is to politely finish the conversation and call back later—until you are satisfied that the person on the other end of the line knows the plan—or ask for a supervisor for clarification. We also make this call even if we know the insurance plan very well. The reason for this is we want to make sure the patient does in fact have this dental insurance; you may also find out from time to time that subtle changes have been made to the dental insurance plan.
Over the years of utilizing this system, some of our office managers have become very friendly with the insurance administrators, whom they may speak to several times per week. This development obviously can work in your favor. If you have good relationships with the insurance administrators, sometimes they will go the extra mile for you to work out a disputed claim or to help your office receive payment faster.
Another important point is to always be friendly on the phone to any representative of a dental insurance company. Dental insurance clerks are human beings, too, and if you don’t treat them with respect, they can end up making your life more difficult. If we already have a treatment plan for a patient, then the office manager will ask the dental insurance clerk specific questions related to that treatment plan.
Once our office manager has the treatment plan in hand, along with the insurance information, she can then prepare an estimate or what we call an in-office pre-determination. It will break down our fees, expected insurance, and the out-of-pocket expense to the patient. At this point we generally underestimate the amount the dental insurance company is going to pay. We do this for a number of reasons. First of all, many times dental insurance companies will use a UCR fee that is below our current fee, even though we know our fees are well within the UCR range for our area. Secondly, the insurance company may deny certain items in the treatment plan that will lower their payment. As you and I both know, there are myriad other reasons that the insurance company will not pay the full percentage of the treatment plan. By underestimating the amount the insurance company will pay by approximately 10%, we are prepared for any of these situations. In this way, if the insurance company pays more than our estimate, then we (via a refund)—and the insurance company—look good in the eyes of the patient. The patient always pays the out-of-pocket expense by the time treatment is finished, even though in most cases the insurance company hasn’t yet paid their portion.
Our in office pre-determination system for the patient comes with a statement on the bottom of the form, “This is only an estimate of your insurance benefits. You are ultimately responsible for the entire fee. Any insurance appeals need to be handled directly between you and the insurance company.”
In cases where the insurance company has really paid what they are supposed to and the patient has paid his or her portion, a refund will be due to the patient. We will send a refund check to the patient at the end of the month. Patients love getting refund checks—they feel as if they have won the lottery. Patients usually receive bills or other notices from the average medical or dental office and are pleased to open an envelope from us and find a nice surprise. We love sending refund checks to patients because everybody ends up happy—the patients feel good because it’s like “found money,” and we feel good because we know our full fee was paid on this case.
We rarely send pre-determinations, also called pre-authorizations, to insurance companies. We only do them when the patient requests a pre-determination or if the insurance company is adamant that services must be pre-determined before payment will be made. Generally, pre-authorizations sent to an insurance company are not beneficial to the dental practice because it requires that the patient wait for treatment. We have all had the experience that the longer a patient waits to get into treatment, the less chance that they will go ahead with treatment. The insurance companies know this too, which is why they always suggest pre-determinations or pre-authorizations. Neither is a guarantee of payment, but is just an estimate of what the insurance company might pay. This is clearly stated on the forms you get from the dental insurance company. Because of this, we prefer to use our system of in office pre-determinations, which comes out to be just as accurate as what you would get from the insurance company most of the time.
What if the dental insurance company doesn’t pay like they are supposed to? As a courtesy to the patient, we will work with the insurance company to find out what the reasons for non-payment are. Many times they are fairly simple and easily corrected. Sometimes, however, these claims can turn into a long drawn out process. Thankfully, these are few and far between. Many times we will give the patient all the information they need to appeal the claim. We also suggest to patients that instead of dealing directly with the insurance company, they deal with their company’s human resource department. Human resource representatives are generally very helpful and will take up the patient’s claim with the insurance company. Insurance company representatives are much more likely to listen and settle a claim that is being brought to them by the patient’s human resource department then they are from the dental office. Frankly, the company that the patient works for is the dental insurance consumer and they don’t need the headache of dealing with a dental insurance company that denies most of their employees’ claims. We have seen from past experience in our office that dental insurance claims that have been repeatedly denied by an insurance company for months are then settled within a couple of days once the company’s human resource department gets involved.
Working with dental insurance can be a challenging experience. Using good common sense and an easy-to-use system can make handling patient insurance predictable and rewarding to both the patient and your practice.