Insurance companies deliberately make it difficult for patients to receive the benefits that they deserve. These are tactics that insurance providers use to retain as much money as possible in the insurance company and pay out very little in benefits payments. Who is the benefactor of these savings? It is not the patient or the employer who is paying the premiums to the insurance company. Insurance companies are the strongest financial institutions in the world and are not in the business to lose money.
At the first new patient appointment, spend time with the new patient to talk about their insurance benefit and how you can help them gain access to the care that they need. Don’t call it insurance “coverage” instead – say insurance “assistance” or “support.” When you say coverage, it creates an expectation that everything should be covered at 100%. By calling it assistance, it lets the patient know that it is there to assist you only.
Insurance companies expect you not to follow-up with predeterminations. If your patient asks you to send a predetermination to their insurance company, use the following phrase:
“If you will give me your permission, I will be happy to send an estimate to your insurance company to see what they might assist you with.”
It is extremely important to stay in touch with the patient during the lag time while waiting for an answer, so let the patient know that you will be calling them in a week or so to see if they have any questions or if you can be of further assistance. It is not enough to just file them in a binder and wait for the insurance company to respond to you. Insurance companies will respond to the subscriber (the patient) and not to the dental office. Your patient needs to know this. If the patient doesn’t hear from you during the waiting period, then they may think the treatment wasn’t necessary or they may have received a reply but may not understand what it means.
The psychology behind the predetermination process is such that if the patient has to wait for four to six weeks, he/she is most likely to not follow through with the treatment. This is especially true if there is an out of pocket expense to the patient. Insurance underwriters include the predetermination requirement in the insurance policy in order to deliberately discourage the subscriber from having the treatment that he/she needs.
Dental insurance is considered a living benefit, which means that if a subscriber has dental insurance, they are most likely going to use their benefit. This differs from most indemnity based insurance plans that only pay out a claim based on catastrophic loss or death. So the insurance companies must find specific ways to slow down the frequency of payments going out while continuing to collect high premiums from employers. How they do that is by including a predetermination process, having a missing tooth exclusion clause, limiting the frequency of coverage for emergency exams, continuing care appointments, scaling units, annual maximums and deductibles, copayments, and anything else that they can impose limits on.
Insurance adjudicators will do everything necessary to decrease the utilization rate of the insurance plan. The simple logic behind it is the more money that flows in from employer premiums and the less that is paid out in claims, the higher the profit margin for the insurance companies.
Traps
1. Not staying in touch with the patient during the lag time. This is the biggest mistake that any dental office can make and one that insurance companies depend on. Many dental conditions are asymptomatic and if the patient is not in pain, he/she is not compelled to move forward with the treatment that they need. If the patient has to wait for four weeks after receiving the diagnosis and treatment plan to see if their insurance company “approves” , the patient is less likely to complete the treatment, but at the very least, payment of the claim has been slowed down considerably, leaving more money in the hands of the insurance company.
2. Telling the patient that you will send a predetermination to see how much of the treatment is covered. The encourages the patient to think that the treatment is not needed unless the insurance company approves.
3. Sending the predetermination by snail mail only. Although insurance companies require x-rays and intraoral pictures for major restorative treatment, sending a predetermination through the mail only delays the processing even further.
4. Waiting for the insurance company to send the response to the office. Insurance companies will send the response to the subscriber to the insurance only.
5. Assuming that the patient will contact you immediately after receiving the response. The responses may be confusing or negatively worded which plants seeds of doubt in the patient’s mind. For example, the response may say that the dentist is charging more than the fee guide that the employer has selected. A patient may interpret that to mean that the dentist is overcharging. They may not realize that it is the employer who selects the plan and it may be based on a fee guide from previous years when you are on the current fee guide.
Top Five Tips
1. Send the predetermination by EDI and by mail simultaneously. Include the estimated lab fee and let the patient know that the insurance assistance includes the same percentage for the commercial lab fee.
2. Manage your patients expectations. Contact the patient one to two weeks after the predetermination has been sent. Ask the patient if they have any further questions and if they have heard from the insurance company. Remind the patient of the importance of the treatment and let them know that you are there to help.
3. Include as much information as possible, i.e. date of the extraction, what other teeth are missing in the arch, initial placement, etc. Send a cover sheet that includes that information. For a sample cover sheet, send me an email at sandie@dentalofficeconsulting.com with the subject line “cover sheet”.
4. Schedule the appointment 3 – 4 weeks after sending the predetermination. This helps the patient to understand that the treatment is necessary.
5. Send a letter of appeal and look at any of the alternative benefits. The Alternative Benefits Clause is written into most contracts. What it means is that the patient will not be covered for the bridge, for example, but the plan will cover an alternative benefit like a partial denture. That doesn’t mean that your prescribed treatment is not what is best for the patient, it only means that the insurance plan will only pay up to a maximum of what the alternative benefit is. Patients don’t always understand that and it is enough of a deterrent for the patient not to have the treatment completed. Once again, it plants the seed of doubt in the patient’s mind that what you have prescribed is not the best way that the condition may be treated.
Insurance companies only care about profit and your patient is only a number to them. You are your patient’s advocate because you really do care about your patient’s health. As dental professionals, it is our job to assist our patients in understanding their benefit and helping them to receive the reimbursement for what the benefits that they deserve and have paid for. Don’t let insurance companies manipulate your patients and interfere with their care and the doctor patient relationship. Follow the tips in this article and most importantly, stay in touch with your patient during the lag time. Dealing with dental insurance benefits is a reality for all dental offices. Understanding their tactics and knowing how to avoid the traps will help you to assist your patients and increase the case acceptance at your office.
