S1 E8: Dental insurance dilemmas

Transcript

Hanlon [00:00:00] Hello, everyone. I'm Dr. Hanlon.

Wright [00:00:02] And I'm Dr. Wright.

Hanlon [00:00:03] And this is Dental Sound Bites and ADA Podcast, where dentists share solutions to challenges in life and at work.

Wright [00:00:10] And today, we're going to be talking about dental insurance. Tune in.

Announcer [00:00:16] From the American Dental Association. This is Dental Sound Bites created for dentists by dentists. Ready? Let's dive right into real talk on dentistry. Daily wins and sticky situations.

Wright [00:00:32] Welcome to our final episode of the premier season of Dental Sound Bites. First, we want to thank all of our listeners and all of our amazing guests this season for all of the learning. All of the pearls of wisdom that you shared with us. The mentorship that I have received from all of our wonderful guests and right here with you, Dr. Hanlon.

Hanlon [00:00:54] Thank you, Dr. Wright. I want to thank everyone, too, for your ideas and for making this a really successful first season for us.

Decoding contracts and billing tips

Wright [00:01:02] And today, the ADA's resident insurance experts are here and they are going to help us decode contracts. They're going to help us talk about billing once and for all and give us some tips and resources to help you get paid. So I want to welcome Dr. Sara Stuefen and Dennis McHugh to Dental Sound Bites. Welcome. Welcome, guys.

Stuefen [00:01:23] Thank you.

Hanlon [00:01:24] We're so happy to have you here.

McHugh [00:01:26] Thank you.

Wright [00:01:26] So let's go ahead and jump right in. Dr. Stuefen, can you tell us a little bit about yourself and your role on the Dental Benefits Council? Tell us what that is and what you do there.

Stuefen [00:01:36] Absolutely. So I'm a general dentist in rural Iowa, and I serve on the Council on Dental Benefits programs. So that is a group of volunteer dentists from across the country that give their time to looking at all things dental insurance. So we're talking about industry trends and what's affecting our offices on a day to day basis. Certain policies that insurance companies are trying to create and maybe cause issues within our practice and trying to kind of combat that and make it work in our offices. And we're also looking at other things like standards for claim forms or the CDT. All those things are within the wheelhouse of that council.

Wright [00:02:19] Awesome. Awesome. I have some questions just flying off in my head right now for you, so I'm definitely going to - I'm excited to jump into those. But before we do that, I also want to introduce Dennis McHugh. So guys, if you've ever called the ADA with an insurance question, you probably have talked to Dennis because he's the guy with the answers. Hi, Dennis.

McHugh [00:02:39] Hi, Dr. Wright. Glad to be here. My name is Dennis McHugh and I'm the ADA's manager for third party payer advocacy, and I work in the Practice Institute's Center for Dental Benefits, Coding and Quality. I've been with the ADA for 22 years. And prior to that, I spent seven years working for the American Association of Orthodontists in a similar role. And what my department does is we help dentists who have problems with their patient's dental insurance. So, for example, let's say there's a claim that the doctor feels strongly that should have been paid. We can intervene and sometimes we can get those paid. Not always, but sometimes we can. Sometimes there's problems with the EOB language that might even impugn the doctor patient relationship. We can contact the plans and ask them to revise that language. There's been problems with dentists trying to terminate network leasing agreements, things like that. Those are all things where we can help our member dentists.

Wright [00:03:31] That is such good information and I know our listeners are going to benefit from it.

Announcer [00:03:39] Announcing the new... wait. This calls for a drum roll. Perfect. Announcing the newly reimagined. ADA member app designed for dentists by dentists. It puts ADA membership in the palm of your hands with features like a personalized news feed member, chat groups, personal documents, storage, even episode exclusives from Dental Sound Bites. The new ADA podcast. Tap into all the possibilities by searching for ADA member app in your app store.

Why is dental insurance a hot button for dentists?

Wright [00:04:16] I want to tell you guys how I feel personally about billing and insurance. First things first. I feel like we just don't learn enough about it in dental school. And of course, it's not that I feel like they deprive us from learning that. It's just they probably can't even fit anything else into the curriculum of four years. So for me, I just feel like there's a big gap. I'm five years out of dental school, so I know that this episode is going to help me a lot with some of the billing and insurance, I guess, struggles that I've had in practice these past couple of years. So I want to ask you guys, why is dental insurance and billing such a hot button for all dentists?

Stuefen [00:05:00] Well, it's something that we deal with every day and probably every hour. So I'm betting just about every dentist listener has had a patient where the dentist has recommended a treatment that they think is best, and then the patient looks at them and goes, "Well, is my insurance going to cover this?" And that's frustration within the office.

Wright [00:05:20] Oh, yeah.

Stuefen [00:05:20] Also, my max is only $8,000. I can't afford to do all that this year. And now we're having to kind of piecemeal treatment to make it work within the patient's insurance. Yeah. All those things that are kind of constantly coming at you every day that you just as a dentist, at least for me, I just want to take care of the patient and do what's best. And that's, of course, interfered with because the patient's trying to work around what they have as a benefit. Another thing that gets frustrating is when the insurance company says, "Yeah, we don't think the patient should have that," or "Yeah, we know you want to do an implant, but we'll pay for a bridge or we'll pay for a partial instead." Right?

Wright [00:06:00] Yeah.

Stuefen [00:06:00] So those things get really frustrating when you're just trying to do the best thing for the patient and insurance interferes.

Hanlon [00:06:07] Unbelievable. So let me tell you how I personally feel about billing and insurance Billing. I love it because I know that means money's coming in at some point down the road. But insurance not so much. I have watched the impact the insurance companies has had on our patients lives for the last 25, 30 years. And I think that we, as an industry and as a society, really need to start looking at this and how can we provide better guidance and value for our patients.

Wright [00:06:38] Yeah, I know. I can remember a time where I've had to do like a peer-to-peer because of that same reason the insurance company denied or said they just didn't see why I was going in one direction with the treatment that I had presented for a patient. And I didn't even know about peer to peer. But luckily the manager at the time did and suggested that I did. Peer to peer with the dental director of the insurance company. And that ended up working in my favor and in the favor of the patient.

Common dental insurance issues and how to avoid them

Hanlon [00:07:08] That's awesome. Dennis, what are some of the common dental insurance pitfalls that are easy to avoid?

McHugh [00:07:13] One of the biggest concerns I hear is, you know, dentists will submit a claim form and they get sent back to them because it was incomplete. Now, I know when you use a practice management system, it's not so much an issue there, but if you're sending in a paper form, please make sure that the form is completely filled out because it gets sent back to you it could take another 30 days or so to get your claim processed. So that's one issue. And along the same lines there, too, as far as documentation goes, as we all know, a lot of insurance companies want certain documentation so they can see that the treatment fits the plan's payment parameters. So, for example, when it comes to scathing and root planning, a lot of companies want to see radiographic evidence of bone loss. So if you forget to submit that radiograph at the claim form, guess what? It's going to be sent back to you and then you've got to send it back in with the radiographs. So be careful to submit all the documentation with the original claim submission.

Wright [00:08:07] Yeah.

McHugh [00:08:08] Another thing to do is to make sure you code for what you do and to make sure you're using the current version of the CDT manual that comes out every year on January 1. But a lot of times, you know, we hear from doctors, they haven't purchased a book in a while. They sent in an old code. Well, if you send in an old code, I guarantee you the claims are going to be sent back to you. So that's another thing that's easily correctable. And the last thing I want to mention, as far as that goes, too, is when it comes to payment, if you can accept electronic funds, transfer EFT payments, it can really make your life a lot easier because you can get paid in less than seven days, sometimes even the same day. So I would encourage dentists to look at that. If you look at our medical counterparts, there's a much higher percentage of EFT use than there is in the dental side. So just throwing that out there for dentists to consider using EFT payments in the future.

Most asked dental insurance questions from ADA members

Wright [00:08:57] Oh, those are some great, great tips. Now, I have a follow up question for you. What's one of the most common phone calls that you receive at the ADA from our member, Dennis?

McHugh [00:09:08] It's really, you know, how much can I charge for a non-covered service? And that gets really confusing at times because first of all, if you're not in that with the plan, you can charge up to your full fee for that service. Even if it's covered service, you can always bill up to your full fee. But if you're in network where the plan, the plan's policies may say that you can only charge the discounted fee for a non-covered service. So let's say, for an example, let's say the plan didn't cover implants. You did an implant. The insurance company is not going to pay for it, but they can limit you to the discounted fee. Now, the good news is that there are 42 states that have passed legislation that says if the plan doesn't cover the procedure, that the doctor can charge up to his or her full fee. So that's the good news. And then the thing with the legislation is, though, that only about half of your patients would be subject to that legislation because about 52% of people have what we call state regulated plans. The other 48% are self-funded plans. And unfortunately, they claim to be exempt from state laws and they claim to be subject to federal legislation, which is known as ARISA. So the bottom line is, if your state has that legislation, it might only apply to about half of your patients. And the other thing I want to mention on that, too, is when you look at your state statute and how they define the term covered service, usually the coverage service includes procedures that would have been covered had the patient not exceeded the annual maximum, for example, or frequency limitation. So even though the claim wasn't paid, if it would have been paid in that situation, it's still considered a covered service and the plan could hold you to the discounted fee.

Wright [00:10:46] We are getting into it, you guys. I hope you guys are enjoying this. So if you are not writing these things down, you may be listening to this on the road, but you're definitely going to want to turn back and play this again once you get to a stationary place. I want to bring you in, Dr. Stuefen, this may come as news to some of our listeners about a service that will help answer specific insurance and billing questions. It's the ADA third party payer concierge. Can you talk to us about how that works, what it is, the benefit to our members? Just tell us all the things related to this concierge service.

Third Party Payer Concierge Service

Stuefen [00:11:23] It really is a concierge service, first class service that the ADA provides to member dentists. Call the ADA Member Service Center if you have some sort of question with an issue that you're having dealing with a patient's dental insurance and they will take care of you. They can't necessarily get insurance to pay, but they're going to help you. So I know I dealt with this with a patient who we were having issues with getting coverage with scaling a root cleaning, and the insurance company was wanting to deny coverage. And I actually contacted the concierge and actually it was it was Dennis who helped me with the issue. We were able to kind of work through it and actually get payment for that patient. And so that patient could actually get their benefit. They will help you. Sometimes they can help you actually call the insurance company and kind of be that mediator within the issue. Sometimes it's just a matter of helping you understand what your contract is with the insurance company and understanding your network contract. Now, between the two of you, can either of you tell us how often our members are using this service?

McHugh [00:12:30] Well, I can I can answer that every day.

Wright [00:12:32] Yeah. Yeah.

McHugh [00:12:33] Yes, every day. So we get there's a couple of ways you can reach us. One, you can call us on the phone or you can send an email to the dentalbenefits@ADA.org mailbox. And either way, we usually get back within 24 hours, if not the same day. But yeah, we get calls every day. I guarantee you that.

The ADA Survey of Dental Fees

Wright [00:12:50] That's amazing. I think this is so important for our early career dentist to know about because sometimes if you enter into practice, especially if you're in a DSO, kind of like I am, and you maybe you're in the office by yourself, or maybe you have someone that's there with you. But it's just really good for everybody to know that these things are available to us. Another thing that recently came out last month in November at the time that we're recording this is our ADA's 2022 Survey of Dental Fees. Now, can either one of you talk to our listeners about that survey, the value of it and how it can benefit our listeners?

Stuefen [00:13:30] So the Survey of Dental Fees is just that. It's a survey of what dentists are charging across the country. You can download that information. You can get kind of a wide scope view of what fees are at different percentiles throughout the country. And then it's also broken down regionally. So you can get an even better idea of the states within your area and what those fees are. So you can see, you know, ten percentile all the way up to that 90, 99th and get an idea of where you stand because fees are. I mean, that's our bread and butter, right? We want to make sure that we're kind of within what's expected and just helps to have a little bit of extra data there to to help us determine that.

Hanlon [00:14:12] That's great.

McHugh [00:14:13] And if I can add on to that, too.

Wright [00:14:15] Please, yes, please.

McHugh [00:14:16] So a common question we get, too, is if a doctor is in network with the plan, what fee do you submit? That your full fee, the discounted fee and the FDA recommends you always submit your full fee. If the insurance company is looking at submitted fees to determine, you know, what they're going to allow. If you're submitting a discounted fee to begin with, you're kind of, you know, watering down that those fees then. So make sure you always submit your full fee on the dental claim form.

Stuefen [00:14:41] And having this information, the survey between the survey and your information, when we're talking about potentially negotiating fees, a fee schedule with the dental benefits company, having that information is so important because the numbers are kind of your power here when you're talking about negotiation. So you've got to have what kind of what the averages are across your state and your region when you're talking to them, because they're going to try and keep you from increasing your fees. And you've got to have that information to work with when you're going in for negotiating.

McHugh [00:15:14] The ADA has put together a toolkit that dentists can use when they want to have those fee discussions with payers. And, you know, we get a lot of calls sometimes doctors haven't gotten an increase in years. Sometimes plans have lowered fees. So on an individual dentist basis, I should say a dentist can try and negotiate fees with the plan. Some plans may negotiate, some may not. But it doesn't hurt to try. And we put together a toolkit which you can find at ADA.org/dentalinsurance. It's just a guide. It kind of gives you some food for thought, gives you some ideas on what to do when you're having those discussions with the payers.

Wright [00:15:48] Perfect. Just for our listeners, this is a free service. Do you like this survey? This is free for you to download, am I right?

McHugh [00:15:56] Oh yes.

Stuefen [00:15:57] For members.

Wright [00:15:58] Thank you for clarifying. Awesome. That's awesome.

Hanlon [00:16:01] I think it's important that everyone take a look at their 2022 survey of fees because one of the things that I recently found out in a practice that I'm in the process of purchasing is that some docs don't ever change their fees. And I was shocked because some of the fees in this practice are at the 50th percentile, which means that you're leaving a lot of money on the table. So don't do that. Take in, look at the survey of fees and make sure that your fees are comparable to the docs in your area.

The ADA’s involvement with higher reimbursement

Wright [00:16:32] Yes, absolutely. Now, another question that commonly comes up that's often seen in social media threads is why can't the ADA advocate for higher reimbursement? I know you are prepared to talk about that today, right, Dennis?

McHugh [00:16:48] Yeah. Yeah. And, you know, I kind of mentioned, too, of what dentists can do. But unfortunately, federal antitrust legislation prohibits organized dentistry from getting involved in the fee negotiations process. And that's a question we get a lot from the members you know the, the frustrated at times. And we understand that. And that's why we put together the toolkit, because a lot of times when a doctor's office a call me and they'll say, well, "I haven't had an increase in years." And I'll ask, "Well, when's the last time you asked for an increase?" And they'll tell me, "Well, I never have." So if you don't ask for it, I mean, the odds of getting one are going to be pretty slim, right? So we've put together this toolkit that you can use. And like I said, some plans may be willing to negotiate and some may not. But it certainly doesn't hurt to ask and have that conversation with the dental plan's awesome.

Medical loss ratio legislation

Hanlon [00:17:34] I want to bring up the big win in Massachusetts for question two. Can we talk about that?

Wright [00:17:38] Yes, let's do it.

Hanlon [00:17:40] For those of you who don't know any information about this, this is the medical loss ratio legislation that we just passed in Massachusetts. And that means that a certain percentage and I believe it's close to 83% of every dollar has to go towards patient value and patient care, which puts the insurance companies on notice that you can't necessarily pay the big dogs first. And those big salaries that the CEO and senior administrators get, you actually have to pay the bottom line with 83% going to the patient and their needs.

Wright [00:18:17] Yes.

Hanlon [00:18:18] So it was a big win for Massachusetts. We've been working on this legislation for a very long time and we finally had the momentum to get it through. I know that any one of us from Massachusetts would be happy to help any of the states out there work on this and inform their legislation as well.

Wright [00:18:33] Right?

Stuefen [00:18:34] Right. Yeah, it's very exciting. Other states are getting excited about it and already drafting legislation. So it's pretty exciting to see where that's going to go and hopefully we can see a change within the dental insurance industry that they focus on patient care and taking care of their customers, you know?

Wright [00:18:50] Absolutely. So how long had that been something that the ADA was working on or I guess the state of Massachusetts and then how it passed so overwhelmingly, I think it was, what, like a 70% or more pass rate, right?

McHugh [00:19:03] Yeah, They actually in Massachusetts, they did a ballot. So the residents of the state actually voted on it. And the ADA committed $5.5 million to help promote it. And 49 state dental associations also contributed to the Massachusetts to help promote that. And I think that we'll see dividends, too, because more states will try to pass this legislation. And remember, before I talked about the non-covered services legislation? That was that the first bill for that came out in 2009 in Rhode Island. And, you know, now we're 2022 and we've got 42 states that have passed that kind of legislation. So we're looking forward to see what happens with the ...

Dental insurance billing advice

Wright [00:19:40] Now, what's the best piece of advice that you guys can share with dentists when it comes down to billing insurance?

Stuefen [00:19:48] So if we're looking just at insurance, you've got to read your contract and it's boring and terrible and it looks long and daunting, but you've got to read your contract before you sign it. I can say I, I bought a practice right after I graduated from dental school and I did not read those contracts. So I signed. I just thought that's what I you know, I was supposed to sign the contract because the previous dentist had signed him and I was supposed to do that. But you can you can make changes in those contracts. They aren't necessarily just, you know, here's what it is and you have to take it. You can you can negotiate on some of those things. So it's really important that you do that. And the ADA actually has a contract analysis service. So they will help you analyze these contracts. And that's again, a free service within your ADA membership. So it's something so important to take advantage of because as a lot of dentists know, once you take on that insurance, once you decide to become in-network, it's a lot more difficult to leave that network, right? Because now you've built up this basis of patients and you're not sure how many are going to stay with you or leave. So use that service and understand because there's so many different things within the uniform policies and the processing regulations that are that benefits companies going to have that can affect your income. So it's not just the fee schedule that you need to be looking at. It's all of those policies that they have where they're bundling and doing all these other things, alternative benefits and all these other things that are going to affect your bottom line in your practice.

McHugh [00:21:24] Yeah, just add on to that too. You talk about like the down coding, for example. We were just looking at a case today too, where if you do a posterior composite, a lot of the plans are only going to pay for an amalgam. And so especially the newer dentist, you know, they haven't seen this. "They'll call us up and say, why are they doing that? You know, my patient didn't want an amalgam." And, you know, we had to explain to them, well, when you sign that contract, there's usually a clause that says you agree to abide by those processing policies. And those are usually found on the web portals. And so you have to it's always a good idea to look at that, too. But there's over 800 different CDT procedure codes. So I know dentist don't want to look at every company's, you know, what they're going to do procedure by procedure, but that's sort of what it comes down to. And the other thing I would add, too, we talked about, you know, the importance of submitting a clean and complete claim form. And dentists are responsible for what goes out in the claim form. So it's always good to do a check of the claims that are being sent out to make sure all the information is correct up to date and that you're using current codes.

Stuefen [00:22:23] So going back to billing and Dennis touched on this earlier, but EFT is and accepting even is within your practice and how much more quickly you can get paid. So that has really kind of revolutionized our practice As far as our biggest payers, we're getting paid typically within a week and if you're waiting for a paper check, you're probably going to be waiting a lot longer for that. And then you're also worried about it getting lost in the mail or just getting lost between your office and how many different hands it gets transferred to and then getting to the bank. So I would definitely recommend if you are a practice owner or working within management of the practice that you take a look at taking of EFTs. It's also just safer. So a lot of people kind of have this concern that the insurance company can actually withdraw money out of the account and they're not allowed to do that. So that's just kind of an important thing to understand. They can put money in, but they're not going to just take money out. And so that's just something that I think sometimes people are scared of taking. And I see that on social media, like people are like, Oh, you have to stick with paper checks but get paid faster and go for it.

McHugh [00:23:36] Yeah, we talked about our website too. You talk about some of the information we have out there. We have a lot of dental insurance guides that are very helpful. We've got a whole bunch of recorded webinars and one of them features doctor stuff and talking about EFT and how that works. And we've got a representative from Nacha, the US Automated Clearing House Association. So that has some very good information. It can help you. You can call the ADA if you have further questions, you can talk to your clearinghouse, you can talk to the payers. There's a lot of room for help out there for those folks that are thinking about doing this but are a little reluctant yet. And also on our website, we've got faqs. We've got all kinds of good information. So I encourage everybody. If you haven't checked out our website too, please do so.

Stuefen [00:24:18] And even to piggyback onto that, just another thing that I think we hear from members, just like a lot of complaints, is virtual credit card payments and that they're being told they have to take virtual credit card payments from these insurance companies and you don't. So call the company and say, I. I don't want to be paid through a virtual credit card. Because, remember, you're probably if you're in network with that company, you're already taking a discount on your full fee for seeing that patient. And then you're may be paying a two, 3% fee for taking that payment as a credit card payment. So don't do that to yourself. Call the company. They have to offer you some other form of payment where you're not where you're not paying a fee. So depending on the company, they might be able to enroll you in EFT. or send you a paper check. But I just I refuse to take a virtual credit card payment within my office. And I think I think that's something that other dentists should do. And then they should also know that they don't have to be charged for an EFT. A lot of times companies will say, okay, well, we'll switch you to an EFT but we're going to charge you kind of a fee for doing this service. And they kind of are saying, you know, we're providing this like extra service for you for doing an EFT, but there is an option that you can do that is a no charge EFT. So they don't they, you can accept that fee, but you don't have to. And so you should know that.

Announcer [00:25:45] On the next gentle sound bites.

Wright [00:25:47] Season two will be here soon, and it's loaded with more sticky situations, amazing guests and a few laughs and lots of resources you can use in and out of the operatory.

Hanlon [00:25:59] Season two coming soon.

Wright [00:26:04] Thank you so much, Dr. Stuefen and Dennis, for being here to share all things with us about dental billing and insurance. It was so lovely engaging in this rich conversation with both of you.

Stuefen [00:26:16] Thanks so much. It was great.

McHugh [00:26:18] It was s pleasure to help.

Hanlon [00:26:19] Thank you. Dr. Stuefen and Dennis, so much for all of your pearls of wisdom. It's been great to really get some more background for our listeners and what we're supposed to do and how we're supposed to manage this very complicated topic and one that we didn't learn about in dental school. We just have to learn through the school of hard knocks. So we really appreciate your guidance.

McHugh [00:26:38] You're very welcome.

Stuefen [00:26:39] Thank you.

McHugh [00:26:39] And for our listeners, you can find everything we talked about today and more on our show notes section at ADA.org/podcast.

Hanlon [00:26:48] If you like this episode, go ahead and share with a friend. Subscribe to the podcast. So you know, when season two starts for us again.

Wright [00:26:55] You can also rate and write a review and follow us on social media.

Announcer [00:27:01] Thank you for joining us. Dental Sound Bites is an American Dental Association podcast. You can also find this show Resources and more on the ADA member app and online at Ada.org/podcast.