Tom Limoli Jr.
It has been said time and again that you only need to follow three rules to make a profit in real estate.Those rules are: location, location, location! The same can be said for financial investing, and the rules here are: diversify, diversify, diversify! Similarly, the three rules of dental-benefit plan interpretation are: the contract, the contract, the contract!
Dental benefit plans come in all shapes, sizes, and flavors. The greatest controlled variable in dental-plan design is the amount of dollars invested to purchase and administer the plan. The higher the premium, the better the reimbursement the plan will generate.. More costly benefit plans generally reimburse at the true 90th percentile of submitted fees, while more cost-effective plan designs may reimburse at 65 percent to 80 percent of the 75th percentile. Nontraditional benefit plans reimburse based on time, not the procedures.
This month, Dental Economics is conducting a fee survey for active practitioners on its Web site (www.dentaleconomics.com). Why all the continued confusion concerning fees and fee-scheduling? Do we think our fees are unreasonable? Do we fear giving away the store? Are we concerned that our patients will receive that dreaded letter from the insurance company informing them that our fees are too high? Or, do we simply want the most reasonable reimbursement for the services that we perform?
As we all know, there is no code that provides separate reimbursement for federally-mandated infection-control procedures. Sterility is not a separate procedure; it is part of the cost of doing business.
The interrelationship of fees is critical. For example, we stress the equal relative value of the two-surface amalgam (D2150) and the importance of it equaling the fee of a one-surface composite (D2330). With this data, we're not telling you how to practice or what your fees should be. However, we are telling you that properly interrelated fees will produce a fee schedule that is both balanced and profitable.
Your fees need to be reasonable. Once you have established a viable and realistic fee schedule, you shouldn't deviate from it unless an individual patient presents with unusual complications. Of course, it's always within the professional's domain to increase fees when complications and/or problems go beyond typical situations. Most benefit-plan consultants are allowed to increase the appropriate reimbursement for any coded procedure up to a range of $100 or 25 percent, when an acceptable narrative with a short description of the complication is submitted.
It is unacceptable for the dental office to have a range of fees for an individual procedure. A fee that ranges from $50 to $70 will usually be reimbursed at $50 and questioned at $70. It would be far more professional and appropriate to list $60 for the procedure and add 20 percent, 50 percent, or 100 percent when an unforeseen complication occurs. Of course, you must inform the patient about any such complication and describe it with the claim.
Now, let's talk money. For the time being, let's forget about checks and credit cards — let's just talk cash. Don't you love it when patients pay in cash? Is it just me or is there something slightly euphoric about the smell and feel of newly uncirculated bills? How about that smirk on Ben Franklin's revised $100 bill?
Do you want lots of cash in exchange for very little investment? Ever think about the potential of your state lottery? What does it take to win the lottery? What do all lottery winners have in common? Do all the winners have a lucky rabbit's foot or an old Indian-Head penny? No, they simply took the time to buy a lottery ticket. The facts are simple — if you don't buy a ticket, you will never win the lottery.
If your patient doesn't agree to take responsibility for the payment of your fee, you are simply trying to win the lottery without first purchasing a ticket. That makes you the loser!
Tom 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 www.LIMOLI.com.