The Most Common Challenges: Understanding the Insurance Challenge

I answer questions daily from dentists and team members needing help on anything from insurance to practice management. Most people tend to have similar questions, so in this series I plan to address the most common questions that plague dental offices.

Understanding the Insurance Challenge

The prior article discussed how to gather great information—through verifications and breakdowns—to use when creating treatment estimates for patients. The next step is learning how to process that information correctly. Insurance can be extremely complex, but thankfully, it’s also highly predictable. It only seems unpredictable when it’s not well understood, which is quite common.

The solution, therefore, is to learn more about how insurance works so that it becomes highly predictable. This is how you can take good breakdown information and turn it into a solid treatment plan where you do not have to rely on the term “estimate,” which patients dislike. This ultimately leads to happier patients and near 100% collection rates.

First, let’s talk about Practice Management Software. Most offices print off treatment plans where the computer calculates insurance for you. The problem here is “garbage in = garbage out. “Most PMS databases are clogged with incomplete or inaccurate insurance plan data, which means the computer has no chance to create a solid treatment plan and estimate. Therefore, there are two options for creating a reliable treatment plan:

1. Become very knowledgeable with the PMS and how it operates, to create great insurance tables, code by code.
2. Create treatment plans manually.

While it may be counterintuitive, option 2 is far easier for most. Insurance is complex, yes, but it’s also routine and follows systems. If you learn the systems, you can create treatment estimates quickly. Yes, they may take an extra couple of minutes vs having the computer do it, but you will save 10x that effort in avoiding problems on the back end, from collections to patient arguments. And even if you do rely on the computer to do most of it, you still need to understand when the computer is wrong.

Some of the most common insurance concepts to understand are:

• Deductible and Waiting Periods
• Maximums
• Frequencies – Exams can be anything from 2x year, every 6 months + 1 day, once per DDS, once per patient, sharing frequency or not, etc.
• Downgrades – Affect the patient’s copay, but not the office’s collections, and are extremely common.
• Limitations and exclusions – Like “bone grafts covered, but only if the patient has an implant rider”. Or “IV sedation is being covered, but only if you are removing ALL the wisdom teeth in that visit.”
• Most common exclusions are restorations for reasons of abrasion, abfraction, erosion, attrition, and wear and tear. So, a crown or veneer would be considered cosmetic or elective and not covered if done for the above reasons. Same with a class V filling.
• Correct coding - A common incorrect coding example is coding an “implant-supported” restoration with an abutment. Or coding a D1110 alternating with D4910.
• Disallows – understanding insurance cannot dictate treatment and tell you not to bill a patient unless they are claiming fraud. Most often, a disallow is the insurance company asking for more information, just not being clear about it.
• Denials – understanding that most denials are either inadequate documentation (which can be fixed) or not understanding the breakdown of benefits (check out the part 3 article). Unexpected denials should be extremely uncommon.

Whether an office is in-network, out of network, or fully fee-for-service, understanding insurance is key to a successful office because the patients still have insurance, they want your help in maximizing benefits.

If you’re serious about becoming more knowledgeable in managing insurance, for the benefit of both your office and your patients, check out the largest resource for dental insurance education here: https://dentalinsuranceguy.com/courses/