Help patients make the most of their insurance

March 1, 2008
What business are you in? Is it a product- or service-based industry? To put it in basic terms, do you make, service or sell widgets?

by Tom Limoli, Jr.

What business are you in? Is it a product- or service-based industry? To put it in basic terms, do you make, service or sell widgets? Take a minute and step outside your office. Is there a sign on your front door? What does it say? Could it be Bill Smith, DDS, Sarah Jacob, DMD, or something along the lines of Happy Tooth Dental Associates? We are in the profession of dentistry and the business of health.

As I have shared with you in the past, the common denominator of all businesses is COD or BOT — Cash on Delivery or Back on the Truck. If you deliver treatment without sound financial arrangements and a comprehensive benefit/eligibility assessment, you will have nothing but meaningless production with its accompanying collection headaches. Is there a better way to skin the cat without upsetting all the PETA people? Yes. The management of various reimbursement systems and the patient’s benefit plan is a simple task if we all follow the path of prosperity rather than that of least resistance.

I will elaborate on rules three and four of my seven keys to reimbursement success. Rule three directs your office to “secure financial arrangements prior to initiating any nonpalliative treatment,” while rule four specifies that the “patient must acknowledge and agree to pay the total fee prior to insurance consideration.”

What is the difference between production and collections? Production is nothing more than the efforts exerted to complete a given task, while collections is the fruits of that exerted labor. Production is not collections. If your office production figures were in fact collections, then those dollars would be reflected in your daily bank deposit. Unfortunately, this is not the case.

The traditional division of labor and accountability has always been one of doctor equals production, support team equals collections, and “I’ll do my job when you do yours.”

Things are different today

It was not uncommon years ago to treat the patient and wait for the insurance to pay, prior to billing the patient his or her individual portion. In today’s competitive marketplace, that old modality of patient administration is nothing more than an invitation to financial hardship and an unnecessary increase in your accounts receivable.

Your patient must agree to be responsible for the total fee in the absence of insurance considerations. Start the conversation by explaining the total fee for the treatment plan. Help the patient understand the fact that his or her benefit plan is designed to help offset the cost of necessary dental care. Insurance does not care about the well-being of the patient, but the employer does. That is why the employer bought benefits, and part of that plan will help pay for part of the cost of treatment.

Does this mean that your office should stop accepting authorization for payment as well as assignment of benefits? Definitely not, provided you follow some simple rules.

Yes, it is the patient’s plan, but if we are going to file for benefits on behalf of patients, it is our responsibility to do the best we can. All too often a dental office’s lack of knowledge results in unsecured benefits and unfulfilled expectations on the part of the patient and dental office. If we choose to provide the service of filing our patients’ insurance benefits, we had better know how to properly handle the process.

What happens when we inform a patient that his or her benefit plan will participate in the reimbursement of dental care? The patient can reasonably expect that the individual financial participation will be at a certain dollar amount. If the plan does not reimburse as expected, do we look for an additional and/or possibly inappropriate coding strategy? I sure hope not!

Patients must take responsibility

Like any goal that must be written down, patients must understand and acknowledge their total financial responsibility. Each patient has a plan of benefits through his or her employer, and that benefit plan belongs to that patient and no one else.

Patients must accept ownership of their plans. Do not apologize for any inadequacies in a patient’s specific plan, and under no circumstances criticize their employer for plan selection. This causes negative feelings.

Establish written financial objectives that can be agreed to prior to the initiation of treatment. These will eliminate confusion and miscommunication.

As for benefit plan specifics … if you do not have specifics in print from the employer or payer from their Web site, do not waste your time and accept assignment of benefit while anticipating a wait for payment. Simply make other financial arrangements — period. Yes, this is a bold step that may encourage some patients to leave your practice and go elsewhere for treatment, but in the long run your financial success and prosperity will be much more predictable and consistent.

As for calling the employer or administrator for benefit plan specifics, this too is a waste of valuable office resources. This time is better spent coordinating treatment and getting the patient to acknowledge his or her need for care.

If you tell the patient anything about the benefit plan, you hold yourself accountable for that information, as well as the overall outcome. We have helped many offices convert patients from insurance dependency.

If your office has been filing claims in the absence of written benefit plan specifics, you and your patients have undoubtedly been caught in a web of modified prosthetic replacement clauses.

Remember the old days when single-surface and multi-surface restorations were routinely benefited every 24 months? How about when full-coverage crowns were benefited every five years? Well, we can kiss those days goodbye.

The old days are gone

Arriving recently on the scene are those traditional, non-managed-care plans that provide no benefit for full-coverage crowns. It matters not if the patient has an existing appliance that is 15 years old. The routine replacement of crowns and fixed/removable partial dentures is not automatically approved for benefit. Prosthetic replacements are more often becoming an out-of-pocket expense for patients. In short, beware the plan that does not cover crowns.

It is not uncommon for employers to modify an existing traditional benefit plan to meet labor-management financial objectives. One of the most popular plan modifications is to provide benefits only to crowns in the posterior sextants of the mouth.

Not so long ago, President John F. Kennedy said, “Ask not what your country can do for you — ask what you can do for your country.” At about the same time we heard America’s dental patients say, “If my insurance doesn’t cover it, I must not need it.” Shortly thereafter these same patients said, “If my insurance doesn’t pay, you obviously did something wrong.”

Today — and in the near future — we need to teach patients to say, “If my benefit plan does not cover the total charge, I understand it is my responsibility. I am glad to see your office still accepts cash.” Remember: If you inform someone before it happens, it’s a reason; if the patient finds out afterwards, it will be nothing more than an excuse.

See you on the road.

Tom Limoli Jr. is the president of Atlanta Dental Consultants and the author of “Dental Insurance and Reimbursement Coding and Claim Submission.” He can be contacted by phone at (404) 252-7808. Visit his Web site at

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