For those of us who do accept dental plans, "Do you take my insurance?" is a question we receive on a daily basis. New patients call to be seen, and this is usually the first inquiry. Patients of record bring in new cards and ask if we accept their company's new dental plan. Some offices will ask for payment at the time of the service. Some will wait until the benefit is paid. Others will not even accept any dental benefit money but will fill out the forms, as a courtesy, and expect payment at the time of service. Finally, other offices will send in pretreatment estimates to the benefit company and ask for the patient's portion at the time of service.
Sheri B. Doniger, DDS.It is a wise practitioner who pre-estimates all dental procedures before starting any treatment. It is not a good feeling for either practitioner or patient when a large outstanding bill comes back and the patient "thought" it was covered 100%, but in reality it was not.
When patients schedule with our office, we have a protocol to determine benefits via a benefit validation form. This form lists all possible paradigms of coverage (expected percentage amount of coverage, deductible, and preventive maintenance schedules) and other contract particulars that are important for both the patient and the dentist to know before embarking on any treatment plan. Some plans have a "robo-response" center, in which you give the patients' name, date of birth, and other identifying information and a fax of coverage is sent. With other companies, you still do get to speak with a real live person.
Yes, no estimate is carved in stone and is not a guarantee of payment. Given that, an estimate still allows you to get an idea of the plan coverage and have a discussion with the patient. It is really good to have this information at patients' initial appointment to have a more thorough discussion about their limits of coverage and financial obligations.
The issue arises when your office does not "take" or is not on a specific HMO/DMO plan in which the patient has to select off of a list of contracted providers to receive treatment. For whatever reason, practices decide whether to participate or not in dental HMO plans. Our practice opted to not participate.
We recently had a new patient come to the office. He was the middle son of a family of five. This young man presented with bilateral abscesses on his primary molars. We took the appropriate radiographs and discussed a treatment plan. We scheduled the young man for treatment the following Saturday. The next question the father asked was, "Do you take my dental insurance?" Since the appointment was on a Saturday, we were unable to validate benefits, so we told him we would contact the company on Monday and let him know.
When my assistant contacted the dental benefit company, we were informed it was an HMO and any charges submitted would not be covered. It is always a patient choice to decide where to have dental care, but when the plan is limited to a "list," that patient is also limited to where he or she will receive dental care. When we called the father and explained the dental choice he had selected, he mentioned there were other options of dental coverage, but the enrollment time was not until December. He had planned on moving his entire family of five to our practice, but now we will have to wait to see if his other dental options fit into his budget.
Sometimes, patients do not have an option of coverage. They are offered one plan and nothing else. Others have choices. Some plans allow for coverage if you are a "non-network provider" at a lower rate or a yearly maximum that may be less than the "in-network" dentists. It is truly incumbent on our offices to educate our patients as to the differences among these plans. The less expensive plan may not be the best in the long run.
The biggest misnomer in this whole situation is the word "insurance." Dental benefits are not the same as insurance. They are an allotment of money that will help defray dental expenses for insured parties. As we know, it takes education to explain to our patients the difference between a true "insurance" and the dental "benefit" they are receiving.
If your business manager (or you personally) are not having this conversation with your patient, you may be setting yourself up for a red flag in the future. It is a good course of action to both validate dental benefits (if you are accepting them) as well as preauthorize any dental care that is necessary.
We did see the young man for a follow-up, but he will have to see an "in-network" dentist to receive care, as the family was unable to pay for outside dental services. We look forward to the family returning to our practice early in 2015.
Sheri B. Doniger, DDS, practices clinical dentistry in Lincolnwood, IL. She is currently vice president and president-elect of the American Association of Women Dentists and editor of the American Association of Women Dentists "Chronicle" newsletter. She has served as an educator in several dental and dental hygiene programs, has been a consultant for a major dental benefits company, and has written for several dental publications. You can reach her at [email protected].
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