Dentist & Dental Insurance: No Love Lost (video)

Dentists not accepting dental insuranceHalf of dentists have mostly or completely stopped accepting dental insurances, according to this survey.

"If all dentists dropped all insurances, then ALL dentists could collect their fees in full from everyone," declared one dentist. "They could also have more leeway to give courtesy discounts to whomever they choose instead of patients who belong to certain plans."

"I'd be cutting ties to 85% of my patient base!" objected an endodontist.

"We converted to [not accepting dental insurance] six years ago," explained one dentist. "We ask for payment at time of service, then send in the claim form for the patient to have insurance company pay them. People have to want to stay with you because this policy can rub many the wrong way. I have lost many a patient over this, but still gain many new patients every month who are fine with it. I have built a strong reputation in my community for personal service, quality, and outstanding cosmetic dentistry. Hopefully that is what keeps them coming back."

"So-called 'insurance' companies must be making a fortune on 'dental insurance,'" fumed another dentist. "When these programs began in the 1960's, the dental coverage limits generally were $500-750 per calendar year. A dental crown cost $100 then. Now, 50 years later, porcelain crowns cost $1000, but the yearly limits are $750-1500. The dental insurance plan premiums have surely kept up with 50 years of inflation, but the dental plan benefits haven't. Do the math… somebody is making a hell of a lot of money on these plans, and it is not the dentist!"

Read more about this dental management survey: Most Dentists Are Dropping Dental Insurances

Dental Insurance Determines Who Will See a Dentist

Dental Insurance Determines Who Will See a DentistDental insurance status is a major determinant of who will seek dental treatment, according to a Facts and Findings report by Rutgers’ Center for State Health Policy.

The report complied data from the CSHP’s 2001 and 2009 New Jersey Family Health surveys on children ages 3 to 18 who received no dental services within a year.

The study found that children with employer-sponsored or privately purchased dental insurance were much more likely to receive dental care than children without dental insurance or even those covered by publicly insured programs like by Medicaid/NJ Family Care.

According to Rudgers University news, the report also pointed to well-care doctor visits as an important indicator of the likelihood of a child receiving dental care, possibly because of efforts to increase dental referrals in managed care plans and the expansion of dental care in federally qualified health centers.

“The odds were three times as great for children who did not have a well-child doctor visit in the past year to not receive dental care as those who visited a doctor,” said José Nova, research project coordinator and lead author of the study. He noted that care for under-served children could be improved with expanded health coverage under the Patient Protection and Affordable Care Act.

Reuters estimates that 45 million Americans do not have dental insurance.

To read more on this report see: Rutgers Study: When it Comes to Use of Dental Services, not all New Jersey Youngsters are Equal

Rollover Plans Aren’t Just for Cell Phones Anymore

Dental Insurance Picks Up the Rollover Trend

A recent dental insurance trend that’s becoming ever more popular, “maximum-limit rollover programs” let patients save unused dental benefits to use the following year. The plans are generally conditional on patients receiving regular preventative care. Not surprisingly, insurers limit the amount patients can roll over. However, the additional money can make dental implants or other complex care a more viable option for many patients.

This new strategy is aimed in part at promoting and rewarding patients who receive regular preventative dental care. It’s nice to see insurance companies realizing how spending more money on regular care will cost less in the long run.

Ameritas Life Insurance and Guardian Life Insurance began the tend a few years ago, and since then they’ve been joined by other major insurers such as UnitedHealth Group, Cigna and Starmount Life Insurance.

Read more

Hygienist Steals Patients, Leaves Dentist with Huge Legal Bills

A Dentist’s Patient List Is Not Protected, Rules Michigan Judge
Watch the video

“Any dentist who’s considering purchasing a practice needs to know what happened to me,” said Dr. Michigan. “My story has global ramifications.”

I could hear an edge of exhaustion in the doctor’s voice. Working seven days a week at two practices is clearly taking a toll. Though he’s been practicing dentistry for over 30 years, this is the only way he’s able to make ends meet.

It wasn’t supposed to work out this way. Dr. Michigan had a solid plan. The practice he purchased was supposed to help pave the way for his eventual retirement. Instead, he got ripped off, and is now looking at close to $100,000 in legal bills.

He decided to purchase an established dental practice that was producing close to a million dollars annually. He wanted to protect the 1,000 or so names on the practice’s patient list, so he had the previous dentist sign a standard non-competition agreement.

“Everyone tells you to have a non-competition clause with the dentist. No one had ever brought up the issue of staff, particularly hygienists,” he sighed.

Along with the practice and patient list, Dr. Michigan also inherited several staff members. His relationship with Hygienist X seemed fine at first. He didn’t mind when she picked up extra hygiene hours at another dental office. Even after she left to work full-time for the other dentist, he wasn’t aware of any problems.

Dr. Michigan knew that production had slowed at his newly-purchased practice, but he didn’t know why until he received a few anonymous phone tips from former employees of the practice where Hygienist X now worked. They had shocking news for Dr. Michigan.

While Hygienist X was still working at both practices, she stole Dr. Michigan’s patient list and brought it over to the other practice, and apparently proceeded to solicit away Dr. Michigan’s patients to the other practice.  She even had the audacity to solicit a patient she was treating in Dr. Michigan’s office! This certainly explained the sharp drop in production he had suffered. He estimates she solicited away nearly 150 patients, costing him over a projected $1,000,000 in lost revenue over a five-year period, according to his consultant.

So Dr. Michigan immediately called his lawyer and started a lawsuit.

You’d think it would be a slam-dunk. In court, Hygienist X point-blank admitted under oath that she had taken Dr. Michigan’s patient list.

Here’s the unbelievable part: the judge threw the case out, ruling that the patient list was not covered under the Michigan Uniform Trade Secrets Act. The judge was in effect saying that a doctor’s patient list is not protected information. (In a similar Pennsylvania case, the patient list was found to be a trade secret, but that’s of little help to Dr. Michigan.)

So Dr. Michigan now finds himself working two jobs just to pay his legal bills. And, as you might expect, he is unhappy. “I wish I could offer you more than just sympathy,” I told him, feeling helpless.

“You can share my story with other dentists,” said Dr. Michigan. “Anyone who’s buying a practice should work out terms with the staff, particularly anyone who has access to the computer, right off the bat. I’d recommend having every staff member sign a strongly worded confidentiality agreement, whether they stay or not.”

A Side Note on the Joys of Insurance

Dr. Michigan’s insurance company would not reimburse him for any of his losses. His Employee Theft and Dishonesty Policy would have given him a payout of up to $20,000 if Hygienist X had stolen equipment or furniture. But his patient list? Sorry, not covered!

But it was a different story for the other dentist in the story. While Dr. Michigan spent a year’s worth of his hard-earned money on legal expenses, the offending dentist’s insurance company paid the bulk of his legal costs.

Taking over an existing practice can leave a dentist exceptionally vulnerable. Patients who have known the hygiene staff for years are suddenly faced with a new doctor. The previous dentist often helps introduce the new dentist to the community, but the hygienists generally have closer personal relationships with patients.

I’ve heard stories of hygienists who leave after a new dentist purchases their practice, only to take out a big ad in the local newspaper announcing that the hygienist will now be seeing patients at another dental office just down the block.

But taking the patient list with you?!? That is shocking, appalling, and blatantly unethical theft. I’m frankly frightened by the possible ramifications of this Michigan ruling.

I would have expected a patient list to be covered by both the Trade Secrets Act and by the Health Insurance Portability and Accountability Act (HIPAA). But apparently not! And patients… Beware too!

Dentists: I want to know what you think of Dr. Michigan’s story! Post your comments below. Plus, contact me if you’d like to get in touch with Dr. Michigan.

Dentist Update: 28 States Considering Legislation on Dental Insurance Fee Capping

Dental insurance fee capping
Our latest survey revealed that 98% of dentists oppose dental insurance companies setting fees for services they do not offer. [Check out the insurance fee setting survey results]

Known as fee capping, this practice has upset dentists nationwide – and legislators have taken notice. According to the AGD, this year, “a total of 28 states introduced 46 pieces of legislation to stop insurance carriers from requiring dentists to accept caps on fees for services the carrier does not cover.

It would seem that more and more dental insurance carriers are moving into the arena of discount dental plans. The insurance companies are trying to negotiate discounts on services they don’t cover. Perhaps they’re getting ready to try both sides of the equation?

It’s important to note that discount dental plans are monitored separately from dental insurance plans. I don’t know what will happen, but I expect it will be interesting…

The AGD provides additional explanation:

Putting Caps on Fees for Non-Reimbursed Services

Several major dental benefits carriers are adding language to provider participation agreements to allow them to set fees for dental services that they do not pay for, i.e., non-covered services. That is, if a dentist agrees to the contract language, he or she will be required to charge the patient what the carrier has told him or her to charge even when the carrier will not pay for the service.

To enact a fee cap on non-covered services, a dental benefits carrier must amend the current contract it has with its existing providers. Here’s an example of such an amendment:

Dentist may bill a Member for non-covered services (which are defined as any service for which no payment is made under the applicable plan or arrangement for any reason, including but not limited to, services in excess of contractual maximums, services not covered under plan design, and services denied due to contractual limitations). Dentist’s charge to Member for non-covered services may not exceed the Maximum Allowable Charge for the applicable CDT code as specified in the most current Maximum Allowable Charge schedule. Fees for all non-covered services will be collected from the Member, and not billed to the Carrier.

Note that this is just one of many variations of such a provision that you may find in your participation contract. The provider then has the choice of signing the new contract, thus accepting the new fee caps, or terminating his or her contract. If the provider elects not to sign, then he or she will be excluded from the provider networks presented to patients by that carrier’s dental plans.

What are the non-covered services?

Non covered services are those services that a patient’s dental plan has chosen not to pay for. Note that a carrier may offer numerous dental plans. Often however, dental plans without coverage for expensive, cosmetic, or other dental services are cheaper for employers to purchase for their employees. This is especially attractive to employers in the current economic climate. Each dental plan may have a different list of non-covered services, and therefore one cannot specify any particular services as universal ‘non-covered services.’

Rationale of carriers enacting such policy

To stay competitive with one another, dental benefits carriers use the argument of market pressure or gaining a marketing advantage as one of the reasons they are implementing this policy. Market need, the carriers assert, is being driven by patients who can save money on services not covered by their dental benefits plan and see value in limiting their out-of-pocket expenses. However, limiting dentists’ charge to patients for non-covered services allows these carriers to market their dental plans as costing patients less without bearing any of the financial risk of the discount; that is, these carriers gain the marketing advantage by shifting the risk to the providers. Therefore, the market trend will drive all carriers to implement similar restrictions in order to avoid a competitive disadvantage. Accordingly, any legislation enacted against the practice of fee-capping for non-covered services must be sufficiently broad to prevent all carriers from engaging in this practice.

Impact to Patients and the Practice of Dentistry

As primary care providers of oral health care, general dentists strive first and foremost for access to quality care for all as the ultimate goal of the profession. However, to serve its patients, a dental office must be viable and sustainable. Today, more patients than ever rely upon dental insurance to be able to afford oral health care. Studies have shown that, without dental insurance, far fewer persons will choose to see a dentist. Understandably, in the present economy, each of us must make cutbacks to our expenses in order to survive. Public awareness and understanding of the impact of oral health on systemic health issues such as diabetes and cardiovascular afflictions is still at its fledgling stages. Therefore, out-of-pocket expenses for oral health are often among the first to be avoided by the public.

Concurrently, businesses including those of dental benefits carriers and employers are also seeking cutbacks. Carriers striving to maintain or increase their revenues and marketshare in this economy offer employers cheaper plans for their employees by covering fewer services and paying less than true market value even for those services they cover. However, by covering fewer services, carriers compel patients to pay for more services out-of-pocket, which they may be unable or unwilling to do. Second, by paying less for the services they do cover, carriers compel dentists to function at a net loss when providing these covered services.

Therefore, today’s dentist must often rely upon billing at market rates for non-covered services to compensate for the loss he or she absorbs in accepting paltry fees from carriers for covered services. However, unlike the carriers’ actions of limiting services they cover, the dentists’ actions do not impose an undue burden upon patients. Here’s why. In the absence of fee-caps for non-covered services, dentists work with each patient on a case-by-case basis to charge what each patient may be able to afford with an understanding that some patients may be able or willing to afford more than others.

Fee capping takes away this opportunity! If fees for non-covered services are capped across the board without regard to what each patient can afford, the practice of the participating dentist may become unsustainable. The result may be two-fold. He or she may no longer be able to offer that specific service to that carrier’s patients, thus limiting the patients’ treatment options. In some markets, providers may feel compelled to stop participating with certain carriers in order to survive. In either case, the patients would face decreased access care.

Call to Action

AGD is currently tracking legislative activity in all states, including fee capping legislation. To see whether your state has a fee capping bill, please click here. The AGD’s Legislative & Governmental Affairs Council and the Dental Practice Council have also approved a legislative lobbying guide called a ‘toolkit’ for AGD constituents. The toolkit will help constituents push the passage of state laws to stop insurance companies from capping fees for services they do not cover. The AGD asks you to contact and work with your constituent organizations to help them use the toolkit to lobby for these state laws. Several states have already introduced legislation to prohibit fee capping by insurance carriers; AGD members are asked to contact their legislators to encourage them to pass this legislation. Click here to see if your state has an action alert on fee capping, or to find your state’s elected officials.

AGD Advocacy: Caps on Fees

Dentists: what are your thoughts on the subject?


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