Three Parts to Consider — You Can’t Have One Without the Others

Dental Insurance Today — April 2017

Love/Hate relationship

No greater dichotomy exists in all the professions of healthcare than that of the love/hate relationship between doctors and the fiduciary responsibilities of today’s Insurance Benefit industry. One provides the loving compassion expressed in the art and science of prevention and healing, while the other coldly enforces contractual financial provisions established by both themselves and their clients.

How much time and effort do you spend fighting with the patient’s insurance? It seems that an entire sub-culture within the various facets of dentistry is focused on not only creating but also fostering conflict. For example, just this month alone, one glossy publication depicted Joan of Arc battling dental insurance, while another portrayed the benefit industry as a masked bandit attempting to circumvent the long arm of the law. Either way, it’s easy to see the love/hate relationship dentistry has with insurance.

Never join any managed care plan that reduces your UCR fees and impinges on your freedom of private practice unless you need patients to fill empty chairs.”
Tom M. Limoli, DDS (1924-2006)

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

Be it marketing or necessity, today’s 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 doctor’s contractual relationship. As patient-driven healthcare 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 patient’s 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?

reimbursement infographic

Above infographic taken from Tom Limoli’s Get Paid System


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 one’s 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.

And 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 Limoli

Tom Limoli

“The Nation’s Leading Reimbursement Expert”

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