Insurance companies seem to hold all the cards with dental practitioners. Due to the ever-changing stance at practices, the stakes have never been higher. As far as participation with insurance companies, now is probably the best time to determine whether to remain in or out of network in some of dental insurance plans.
Consider Dr. Roy Shelburne, a practice owner, father, and grandfather found guilty of healthcare fraud, racketeering, and money laundering. As a result, he was incarcerated for 19 months.
Dr. Shelburne now makes it his mission to share his experience gained with other dental professionals. According to him, “A wise man learns from his mistakes. But it is a wiser man, still who learns from somebody else’s.” Today he dedicates efforts as a speaker, author, consultant, and ADA subject matter expert.
In this article, Dr. Shelburne will share guidance on dealing with dental insurance and PPOs today and determining whether dentists should still be in-network or move out of a network.
Remaining in-network may provide several benefits, but a very keen sense of participation is essential. The only way to properly determine its impact on dentists and their practices is through tracking.
Dr. Shelburne explains what to take into account to evaluate the contribution of dental insurance plans to a practice:
For those who are in-network, charges should always be on the claim form to track the write-offs. Insurance companies may provide substantial fees, but it is not the only aspect an insurance plan requires. Regrettably, dentists barely read the fine print to learn the obligations. Other restrictions and limitations on the program extend beyond the write-offs. These guidelines may limit reimbursement and the collection of payments from patients.
Putting the full fee on write-offs can make tracking more convenient due to the following:
For example, a patient receives a crown procedure and uses primary and secondary insurances. The primary insurance has a limitation of $900, while the second has $700. The patient will get the perk of $700, and that’s the maximum amount they can get for the crown procedure. However, if the combined insurance payment is $950, dentists need to write-off the $50 down from the $1,000 crown fee.
3. Insurance aging
Be sure to track insurance aging: 30, 60, and 90 days. Always take note of claims not submitted, and run that report daily. All requests must be released on time.
4. Rejected claims
Track rejected claims to review why they were denied to ensure they won’t occur again. Common causes of rejected claims are use of an incorrect code, or a repeated error. Distinguishing and resolving the mistake may significantly reduce the resources spent on re-submitting claims.
When re-submitting a claim, have the following available:
With COVID-19 protocols leading fewer patients to visit dental offices, dentists must identify which plan is most favorable to their current situation. Tracking and reviewing the items mentioned above will help create a resolution.
“Communication skills are vital,” said Dr. Shelburne. Every person in practice needs to address these questions from patients:
Communicate the information clearly and accurately so that dentist and patient are on one page. If not addressed well with patients, the outcome might be, “You’re not taking my insurance anymore, so I must switch dentists.”
What’s essential? Knowing how to discuss the topic with patients.
According to Dr. Shelburne, the following statements must be avoided:
Never suggest that the insurance will or will not do something. Even with a pre-estimate indicating it would cover a particular dental procedure, a disclaimer exists that there is no payment guarantee.
Never send pre-d unless the insurance company asks for it. Also, remember that sending in a pre-d will only delay the process and allow a patient time to decide against the procedure.
Saying this to a dental patient is against the law. The American Dental Association (ADA) considers any attempt to collect copayments and deductibles as overbilling.
2. “We will bill your insurance and send you a statement after we receive the insurance reimbursement.”
Never wait until the Explanation of Benefits arrives to bill a patient. Be very diligent about having the correct information on your database. Make an accurate estimate and collect the patient portion before service or at time of service. Otherwise, plan to spend a lot of time pursuing payments.
3. “No, we do not take your insurance (unless you do not file or accept assignment of benefits).”
Instead of saying “no,” lead patients into a conversation where it’s possible to help them understand why the practice does not accept their insurance.
Communicating changes to your patients, including dental insurance, will help gain understanding and trust. Let them know and feel that a proper evaluation was made before arriving at that decision.
Most patients find it difficult to understand their benefits. Having many different plans and contracts can be confusing for them. Besides talking with them, providing patients with a written guideline would ensure that all on one page.
As explained by Dr. Shelburne, more and more limitations will arise in dental insurance plans. Employers are searching for ways to minimize the charges and the expenses they incur. He also mentioned that PPO plans will continue to thrive because employers and patients want to have the most cost-effective products and services. The only way to promote cost-efficiency is by cutting benefits and establishing limitations. Nevertheless, some practices can make it work.
In contrast, practices that want to provide a very high level of care may find it impossible to exist in a PPO environment. It’s not possible to run a high-touch, boutique type of practice and be a PPO practice at the same time. A PPO patient will generally select doctors in PPO.
With the limitations in the industry today in mind, Dr. Shelburne suggests four ways that dental professionals can thrive in their practice.
Whether a practice should be in-network or out of network is a decision that must be made by every dentist. Nevertheless, as Dr. Shelburne advised:
With all things considered, dealing with dental insurance and PPO plans means understanding the rules and playing by them. Let this guideline from Dr. Shelburne on insurance participation helps decide whether to hold ‘em or fold ‘em.