Limoli & Associates | P.O. Box 420505 | Atlanta, GA 30342 1-800-344-2633 [email protected]

Summer has now officially begun. At the same time, so has hurricane season. Add to the overall mixed messaging of current events and we, as well as our employees and patients , also have to deal with $5.00 plus per gallon gasoline. Complicate spiraling inflation with todays somewhat bizarre, post-pandemic, interpretations of “supply and demand” it’s no wonder both costs, and prices are shooting through the roof.

Dentistry and the world of reimbursement is in no way exempt from these considerations. We have a clinical as well as administrative labor shortage, and the immediate solution seems to raise procedure fees in order to compensate for the reality of dwindling “supply” and increased “demand.” 

Now comes the reality of more closely examining your most significant as well as consistent contributor to your bank deposit. Yep – I’m talking about your patients benefit plan and its role in making your dentistry affordable. Now is the time, for us together, to reexamine the reality of these plans as well as their overall form and function in the delivery of dentistry.

There are many perspectives as well as objectives when considering what to do with and about the patients plan. No matter how you individually want to interpret the patients insurance, whether you’re in or out of network, you must acknowledge the three separate phased functions of the patients plan. They are:

  1. Before the patient visit
  2. During the patient visit
  3. After the patient visit

Now look in the mirror and ask yourself, as well as the other members of the team, what are the roles of the patients insurance in your practice? In order to simplify and streamline the overall reimbursement process, each of the three must have its own distinct parameter. In separating the three, we have to understand and respect the fact that no single phase can logically exist on its own without the supporting interdependence of the other two. Yet, when we pull all the pieces together, we see that the administrative, clinical, and executive teams of the dental office are all interwoven into successfully identifying and managing the role of the patients insurance in a dental practice. Let’s take a closer look.

Before the visit

So how did the patient come by selecting to inquire about an appointment with your office? If it was a referral from an existing patient, you did and have been doing it right. Congratulations and well done! 

Now look one step further — what is the relationship of that existing patient and the referral? Are they a social network friend, neighbor, coworker, classmate, etc? If they share the same employer, they probably share a similar benefit plan. If not, how did they come by selecting the practice? Most often we find “being on the list” or “finding out if you are on the list” is the driving question that initiated the preliminary point of contact. 

A word of caution — don’t fall victim to the manipulative “verbal judo” praised by some of the unethical teachers of practice management. To twist the patients question into a responding generic true statement in order to make the appointment and get the patient in the door, has and will continue to destroy the public reputation of many a fine clinician.  Telling a perspective patient, “We work with all insurance” is not truthfully responding to their question. Your reputation problems are just beginning when the patient sees their EOB and learns they would have saved money had they gone in network. 

If one teaches how to manipulate others based on personality types and styles — they are probably already manipulating you.

Be it marketing or necessity, todays patients see themselves as driven by the decisions of their benefit plan. In many parts of the country where communities are controlled by dominant employers, participation in network is not optional. Now, bring into consideration the changing scope of what was and currently is defined as a doctors contractual relationship. As patient driven health care decision making continues to increase, payers will develop more cost saving “network within a network” options to satisfy their clients. 

During the visit

Dealing with the patients benefit specifics is easy and transparently automatic when offices realistically embrace the concept of “treat the patient, and not their insurance.”  In many ways, this can be easier said than done. Old habits are hard to break, but how often are offices calling insurance companies asking patient specific information concerning frequency limitations? Is this information being used for the purpose of diagnostic based treatment or finances? It has to be one or the other. Making it both drives the patient to say, “I only want what my insurance pays for.”

As concerns treatment, the insurance simply requires that you code and bill them for what you finished. Not what you started. Not what you think you started. Not what the patient said they wanted. Code for what you finished. And, finished means done.

After the visit

The patient reached out to the office. The appointment(s) took place. The doctor diagnosed. The various treatment options were presented. A treatment plan was accepted. The patient agreed to the total cost of care. The terms of payment for the accepted treatment plan were presented and accepted. The treatment is rendered. The financial ledger now reads $0.00. It is done.

But where is the insurance? 

In conclusion, please allow me the courtesy of going on the record in stating, “I am neither for or against the insurance industry.” To take a steadfast and partisan perspective in absence of understanding ones own individual situation is both foolishly unwise and belligerently selfish. 

  • If you don’t want to be in network with the plan — don’t join. 
  • If you are miserable being in network with the plan — get out.

on that same note

  • If your market situation requires you to be in network — sign up.
  • So that you don’t lose your mind and your overall profitability while being either in or out of network — call me.

It is my honor to be of service.

Tom