Insurance coverage shouldnt affect diagnosis

Some dentists, the author finds, are diagnosing insurance benefits, not the best course of treatment.

Some dentists, the author finds, are diagnosing insurance benefits, not the best course of treatment.

Paul Zuelke

The bridge and other treatment the doctor has diagnosed for Mrs. Smith comes to $3,700. "We have checked your insurance," the doctor tells her, "and find that you have an annual maximum benefit of $1,000. Since the diagnosed treatment is covered at 50 percent, why don`t we do $2,000 worth of work now and do the rest of the work next year."

"Mr. Jones, the crown you need comes to $520. You have already reached your maximum insurance benefit this year, so let`s wait until the first of the year to schedule this work."

Have you ever heard statements like these made in your office? Over the past few years, as I have traveled around the country and visited dental offices, I have heard these and related presentations many times. In other, more extreme, (but not uncommon) instances, I actually have seen doctors and staff presenting only the treatment immediately covered by dental insurance. As more insurance becomes available, more treatment is presented.

These offices are missing a critical point: Insurance companies do not yet run the dental profession. I am not clinically trained as a health-care provider; however, I believe doctors are trained to diagnose, and present exactly the treatment needed to bring their patients to optimal health. Doctors are not trained to diagnose insurance benefits. Doctors are not trained to diagnose patients` pocketbooks. Doctors are not trained to diagnose minimum-acceptable or secondary courses of treatment. The doctor`s responsibility is to diagnose the best possible course of treatment, treatment that will bring the patient to the best possible oral health. Neither a patient`s financial condition nor insurance coverage should affect diagnosis or clinical presentation.

I depend on my personal doctor to tell me exactly what care is needed, even what is likely to be needed in the future, to bring my mouth and teeth into perfect condition. I make my own decisions about my financial ability to pay. If I cannot handle the cost of the recommended treatment, then, and only then, would I expect my doctor or his designated staff member to present a secondary course of treatment. I appreciate being informed of the insurance coverage I may have available; however, I expect and count on my doctor and his staff to assume I have a better ability than do they to determine what is affordable to me.

Insurance is a wonderful benefit for patients and, properly handled, dental insurance will truly enhance case acceptance and practice productivity. By accepting assignment of insurance benefits, a dental practice will provide the means for many patients to accept dental care that they may otherwise have chosen to do without. Our internal studies of over 700 practices show that practices accepting assignment of insurance have significantly better new-patient flow, case acceptance and production per hour worked than do practices not accepting insurance. However, the practice must always be willing to diagnose, present and "sell" treatment independent of a patient`s insurance coverage.

The author is president and founder of Zuelke & Associates, Inc., a management-consulting firm specializing in teaching credit management and accounts receivable-control techniques to health-care practices. He is the author of "Cash or Credit?, A Nuts and Bolts Guide to Effective Credit Management," published by Penn-Well Books. He has authored many articles and lectures extensively at local, state and national meetings.

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