Carol Tekavec, RDH
One of the most persistent problems faced by dentists and staff is answering patients` questions concerning their insurance coverage. Staff members frequently are frustrated because they are required to serve as the "middlemen" in the insurance relationship. Although a patient`s dental contract typically is between the patient`s employer and the insurance carrier, the insurance company is far away. However, the office receptionist or office manager is right there in front of the disgruntled patient.
Some offices have become so irritated by the constant need for patient explanations, they have discontinued accepting patients` insurance payments. While this is an option, most offices need insurance patients ... and their insurance patients need help. Many patients would not be able to accept any dental treatment without the financial assistance their insurance offers. They often are unable to navigate the confusing insurance labyrinth alone.
The best way to prevent problems is for the office to commit to the well- established principle of "inform before you perform." This is even more imperative in an insurance situation. A detailed and complete treatment conference, where all recommendations are explained, fees discussed, and questions answered, is the best defense against the dreaded EOB (Explanation of Benefits) form. When patients understand why they are having a treatment, as well as what it ultimately will cost, the EOB becomes what it truly is - simply an explanation of what the insurance will pay for, not what the patient needs.
If a patient does not understand the need for a treatment and payment is denied, he or she wonders if the treatment really is necessary. The mentality that "if insurance doesn`t cover it, it must not be important" is a tough one to counter. It also is almost impossible to fight after the fact. When a patient understands and accepts a procedure - and when basic insurance concepts are explained in advance - the EOB loses its sting. One of the best statements that can be made during a treatment conference is, "Your insurance will cover a portion of what you need, but not everything." This should be repeated frequently.
Even after the very best treatment conference, issues can arise. Let`s look at some common patient-insurance questions and some potential answers:
Question: I thought my insurance covered 100 percent of my treatment. Why does your statement show a balance due?
Answer: Insurance companies base their payments on what an employer has contracted for. This typically is a percentage (often 75-90 percent) of a table of fees for a given zip-code area, with only preventive procedures being paid at 100 percent of the fees allowed. The insurance benefit usually is not the same as our office fee. As we discussed during your treatment conference, our office is obligated to provide you with the treatment you need, but your insurance carrier only is obligated to pay what the contract calls for.
Question: Why do I need to come in for cleanings so often? My insurance only pays for two a year.
Answer: As we discussed during your treatment conference, you have a gum condition known as "periodontal disease" that requires more frequent and a different type of treatment than simple cleanings. While your insurance does provide some benefit for periodontal treatment, a significant portion is left for the patient to pay. Even though your insurance will not cover everything, we always must recommend what you truly need. We can`t compromise on your care, but we can do our best to help you get the benefits you deserve.
Question: Why did my insurance pay so little on the tooth-colored fillings in my back teeth?
Answer: Insurance contracts typically only cover the "least expensive acceptable treatment." Insurance seldom pays for what the carrier considers to be "cosmetic treatment." During your treatment conference, we talked about the tooth-colored materials we use in our office. Even though amalgams are considered acceptable for posterior teeth, you decided that you preferred the white fillings. As we expected, your insurance paid the amount the contract allowed for a silver filling."
Carol Tekavec, RDH, is the author of two insurance-coding manuals, co-designer of a dental chart, and a national lecturer. Contact her at (800) 548-2164 or at www.steppingstonetosuccess.com.