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Help patients make the most of their insurance

March 1, 2006
What business are you actually 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.
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What business are you actually 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? Does it say Bill Smith, DDS, or Sarah Jacob, DMD? Or is it something along the lines of Happy Tooth Dental Associates? Remember, 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 business is COD or BOT. That means it’s “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 of the PETA people? Yes. The management of various reimbursement systems, as well as the patients’ benefit plans, is a simple task if we will follow the path of prosperity rather than that of least resistance.

Of my seven keys to reimbursement success, I want to focus on Rules 3 and 4. Rule 3 directs your office to “secure financial arrangements prior to initiating any nonpalliative treatment,” while Rule 4 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 fruit of that exerted labor. Production is not collection. 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 = production
support team = collections
“I’ll do my job when you do yours”

Years ago, it was not uncommon to treat patients and wait for the insurance to pay prior to billing them for the amount they were responsible for paying. 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 acknowledge and 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 patients understand the fact that their benefit plan is designed to help them offset some of the cost of necessary dental care. Insurance does not care about the well-being of the patient; their employer does. That is why the employer bought a plan, and the benefits will help them pay only a part of the total cost of treatment.

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

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

What happens when we inform patients that their benefit plan will participate in the reimbursement of their dental care? Patients have a reasonable expectation that individual financial participation will be at a certain dollar amount. If the plan does not reimburse as expected, are we now looking for an additional and/or possibly inappropriate coding strategy? I hope not!

As with any goal that must be written down, patients must understand and acknowledge their total financial responsibility. They have a benefit plan through their employer, and that benefit plan belongs to the individual patient and no one else. Make patients accept ownership of their plan. Do not apologize for any inadequacies of the patient’s specific benefit plan, and under no condition should you criticize their employer for plan selection. This causes unnecessary negative feelings.

Have written financial objectives established and agreed to prior to the initiation of treatment. Having your financial policy in writing always eliminates confusion and miscommunication.

If you do not have the specifics of a patient’s benefit plan in print (from the employer or the plan provider), do not waste your time by accepting assignment of benefit and then anticipating a wait for payment. Simply make other financial arrangements - period. Yes, this is a bold step that may lead some patients to leave your practice and/or go elsewhere for treatment, but your financial success and prosperity will be much more predictable and consistent in the long run.

As for calling the employer and/or administrator for benefit plan specifics, this is a waste of valuable office resources, too. This time is always better spent coordinating treatment and getting patients to acknowledge their need for care. If you tell the patients anything about their 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 benefit plan specifics, you and your patients have undoubtedly been caught in the web of modified prosthetic replacement clauses. Remember the old days when single- and multi-surface restorations were routinely a benefit every 24 months? How about when full-coverage crowns were a benefit every five years? Well, you and your patients can kiss those days goodbye!

Recent arrivals on the dental benefit scene are those traditional, no-managed-care plans that simply 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 as a benefit. Prosthetic replacements are more and more becoming a patient out-of-pocket expense. In short, beware the plan that does not cover crowns!

It is not uncommon for an employer 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.

In the early ’60s, we heard President John F. Kennedy say, “Ask not what your country can do for you, ask what you can do for your country.” About the same time, we heard American 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 very near future - we need to teach and allow our patients to say, “If my benefit plan doesn’t cover the total charge, I understand it to be my responsibility. I am glad to see your office accepts cash and credit cards.” Remember, if you inform patients before it happens, it’s a reason; if and when they find out afterwards, it will be nothing more than an excuse.

Tom M. Limoli Jr. is the president of Atlanta Dental Consultants and the editor of “Dental Insurance Today,” a bimonthly publication that addresses third-party reimbursement in the dental office. He also is 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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