Insurance covers this ... right?

An ADA survey in 2000 indicated that a lack of insurance was the top reason most respondents listed for not visiting the dentist.

By Carol Tekavec, RDH

An ADA survey in 2000 indicated that a lack of insurance was the top reason most respondents listed for not visiting the dentist. While a few dentists have been successfully converted to "insurance-free" offices, this is not practical for most dentists. In fact, many dentists rely on their indemnity-insurance patients to provide the backbone of their practices.

Problems arise because patients do not understand what their indemnity insurance is designed to do. Many believe their insurance will cover treatment at "100 percent." Patients' misconceptions about dental plans cause problems between the staff and the patient as well as the patient and the dentist. The office is always in the "middle." When insurance doesn't pay what the patient thinks it should, instead of being angry with the carrier, the patient gets mad at the dentist. When estimates of benefits are returned with denials, or reasons for reductions in payment are difficult to understand, or when the insurer states that fees exceed the "usual and customary," patients mistrust the dentist and wonder why he or she charges so much. How can an office prevent some of these problems?

One helpful tactic is to prepare answers to common questions in advance. Better yet, consider printing up a Q&A sheet or purchasing a brochure on dental insurance, written in laymen's terms, to distribute to your patients.

Here are a few common questions that cause headaches for dental offices. Potential answers follow each question.

Why doesn't my insurance cover the cost of my dental treatment?

Dental insurance isn't really insurance (defined as a payment to cover the cost of a loss) at all. It actually is a benefit, typically provided by an employer, that helps employees pay for routine dental treatment. The employer usually buys the plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost of treatment.

But my plan says that my exams and certain other procedures are covered 100 percent.

That 100 percent generally refers to what the insurance carrier allows as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge for that service.

I received an Explanation of Benefits from my insurance carrier that says my dental bill exceeded the "usual and customary." Does this mean that my dentist is charging more than he/she should?

Many carriers refer to their allowed payments as UCR, which stands for "usual, customary, and reasonable." However, this does not mean exactly what it seems to mean. UCR is actually a listing of payments for treatment negotiated by your employer and the insurance company. The payment listing is related to the cost of the premiums and the geographical area where you live. In almost all cases, the payments are usually less - and frequently much less - than what any dentist in your area may actually charge for these dental procedures.

My insurance plan does not go into effect until next month. Why won't my dentist do my treatment today, then send in the claim next month so my insurance will cover my treatment?

Individual state laws regulate these issues. It is insurance fraud to change the dates of service on a claim! Both the patient and the dentist can be prosecuted for doing this.

Dispassionate, prepared answers like the examples we have presented can help free the dentist and staff from undue pressure. To view a sample patient brochure on dental insurance, visit my Web site at www.stepping stonestosuccess.com.

Correction

The Insurance column in the May 2002 issue contained an error. It should have read, "The following eight situations are generally viewed by insurers as fraud," rather than "eight fraudulent practices that dental offices regularly commit." Dental Econom ics regrets the error.

Carol Tekavec, RDH, is the author of the Dental Insurance Coding Handbook-2000, co-designer of a dental chart and an informed consent booklet, and a national lecturer. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com.

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