Dental Insurance – Learning Beyond The Breakdown – Volume 1

I’m excited to introduce to you the first of several articles I will be writing about Dental Insurance. My goal is, to explain the ins and outs of dental insurance so that any employee, veteran or green, can truly understand insurance. Not just how to send a claim or print a treatment plan. I will provide a complete, overall understanding of insurance, including how and why it works the way it does. The goal is to provide better treatment presentation to the patient in which scheduling their health is determined by necessity, over coverage, and to reduce the stresses brought on to the practice and the patient because of insurance.

How or where do I even start? It took me some time as I began this article, to figure this out. I could start with the easy stuff like, maximums and deductibles, the birthday rule, or fee schedules, but I’ll break that down later. For now, I want to discuss the overall system of insurance.

Do you take my insurance?

There’s many ways to answer this question, some of which should never be repeated out loud but, but that topic is for another article. For the most part, if the insurance plan is a PPO, the patient can basically go wherever they want but, will have a lower copay, if at all, if they go to an in-network provider. This is starting to be the case more frequently, due to all the newly graduating dentists coming into the scene and signing up to be in-network with several insurances to obtain new patients. A fact about this I’d like you to notice is that, these new dentists signing up with most of the insurance companies out there (including Delta) are signing up to receive, very low compensation for the procedures they are performing. This can lead to having to cut costs somewhere (I’ll let your imagination ponder that for a moment.)

It’s important to understand the value of what a dentist does for a patient and their health. The worth of treatment cannot (or should not) be measured by how cheap it was, compared to some other dentist. If WE truly understand this as the liaison between patient and dentist, we will be able to convey it. To answer the question, we must place value on the dentist and the service they provide so that Insurance, doesn’t get to interfere with a patients decision to put quality, above cost.

The brutal truth about insurance was depicted very clearly in an unlikely family movie. I’ll never forget when I watched the scene in the Incredibles by Disney/Pixar, where Mr. Incredible’s day job at the insurance company, didn’t allow him to pay out on a claim, even though it rightfully qualified. Mr. Incredible hated it, lost his cool and quit that job. I was like, “yup, it is sooo like that!” If you’ve been in the field of dental billing, you can totally relate. (I will be writing about how to minimize your denials by at least 50% in this series.)

WE have to understand that we cannot trust or rely on the insurance. The very first thing you hear when calling or any documentation provided by the insurance is “This is not a guarantee of payment”. They do not want to pay if they don’t have to. They WILL NOT pay, if they don’t have to. So what, the member pays $XX premiums every month, insurance WILL NOT pay if they find a way not to! It’s truly mind boggling when you read some of the clauses of how certain procedures will not be covered even if it’s medically necessary, along with so many other clauses. I don’t understand how it’s even legal to have some of those clauses but I guess that’s why I’m not a lawyer. Once you understand this, you will be able to avoid lot’s of mistakes, sometimes costly ones.

Insurance is forcing many dentists into providing lower quality services. This mostly applies to the newer generation of dentists. The dentists that have been around for over 10 years have been grandfathered into fee schedules that were negotiated at higher rates, namely Delta Dental Premiere plans. In comparison, Delta PPO plans which are non-negotiable, pay out approximately 50% less those Premiere plans do, and are the only option new dentists have to sign up for with Delta. Delta provides Premiere plans to the new dentists but in effect only get paid off of this schedule if the member’s plan is a Premiere only plan, which is rare. Don’t get lost, I’ll explain further. When employers provide benefits, they negotiate fee’s and coverage with the insurance. Many employers choose PPO only, plans because it’s less out pocket. (A deeper look into this will be included in this series.)

Why did I say dentists are providing lower quality service? Well, let me share a real life example. I witnessed an office that didn’t get around to credentialing all of their dentists with Delta Dental as they were each hired. The owner was originally contracted and the subsequent dentists hired to join the practice, were being billed out under the owner. Delta audited the practice and informed the owner of the error in which, all the additional dentists had to be credentialed but by this point the option was PPO (with the so-called “Premiere plan”.) Additionally, Delta sends payments directly to the member if the dentist is not contracted with them. Talk about twisting someone’s arm.  The office went ahead with credentialing their dentists but the practice lost over 50% of its income… staff members were let go, compensation was affected, the remaining staff is overworked, and the office now has to see twice as many patients in a day to make up the difference. A practice has to cut corners somehow, in this example cutting down staff and increasing foot traffic. Other ways to cut costs are, using lower quality materials, paying low rates to employees, adding upgrade fee’s to procedures, spending less time with patients and rushing through treatment.

Things have to be put into perspective, to make sense to us. If we understand these things and how working with insurance companies affects the dental practice along with the basics of how the business operates, we will be able to persuade our existing and potential patients in the right direction when it comes to scheduling and proposing treatment. We’ll also understand why we need to collect from the patient at the time of treatment and also helps us submit claims in a timely manner with all of the supporting documentation to minimize denials.


Key Points I want you to take from this:

In order to provide the best service to your patients, you should understand insurance beyond obtaining a breakdown.

Insurance will not pay if they can find a way not to and they never guarantee anything.

Dentistry is becoming devalued by insurance if we allow it to.

We must see value in the dentist/s we work with to convey value to our patients. (If you don’t see any true value in the dentist you are working with, you might want to find another place to work. Personally, I cannot convince patients of anything if I don’t have faith in that particular dentist.)

Don’t sit back and let valuable patients leave the office just because your office is not in-network with a particular insurance.

Stay tuned for the next article!





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