Second Opinion: Questions we should be asking insurance companies -- Part 2

2015 04 07 14 38 32 487 Hirsch Jason 200

As I wrote in the first part of this series, it's important for dentists to understand what is being sold on the marketplace, as we will bear the brunt of the customers' feelings and the payment, or lack thereof, if we sign up to participate with these insurance companies.

Jason P. Hirsch, DMD, MPH.Jason P. Hirsch, DMD, MPH.

I want to know what the national average is for reimbursements versus what the average fee customers are paying in premiums for the three preventive services (exam, prophy, fluoride). This will allow us to gauge if the value proposition makes sense to the customer.

If people are paying nationally on average $400 for $300 worth of services, then both the patient and the provider are being cheated. Guardian Life does roll over some of that money. This is the first time I've seen an insurance company do this, but still we need to know the value. If Guardian wants us to partner with them, then we have to have complete transparency. If they cannot show us the books, then the system of wellness can never be achieved. Unlike other businesses, healthcare is not something that can be sold -- it has to be embraced.

We have to put patients first in our business relationships. Insurance companies, in reality, are nothing more than a paperwork system and a payment system. They have no incentive to switch to a wellness-based system unless you force them to.

It's also more difficult for the insurance company to raise premiums if everyone is underutilizing services because they are healthy. When I negotiate with insurance companies, I only work with ones that pay me 90% to 100% of usual, customary, and reasonable (UCR) rates for my top 20 prevention codes in lieu of 50% for my restorative codes. I make them put their money where their mouth is.

My tactic does afford the insurance company room to raise premiums, as we place emphasis on more frequent wellness visits. The cost can be passed onto the customer if the customer is getting value. My payment system aligns prevention with a business model that put the patient first, me second, and the insurance company third. Any deviation from this pecking order and the system of wellness is destroyed.

Value proposition

When customers discover that there is little value in something they purchased, they become upset at both the insurance company and the dentist. I've been on that end of disgruntled patients whose insurance company declines a preventive service or sets a limit of once per year.

“It's time to put the people's money where their mouths are -- that's in our offices but on our terms.”

The first thing they resent is the insurance company for being sneaky; the second thing they resent is you, the dentist, for partnering with a company that has shady practices not aligned with patients.

We must as a profession define what the insurance company has to cover and how much it has to pay, as nobody in the Obama administration stepped up for pediatric dentistry or dentistry in general. Increasing overhead and declining or flat-line reimbursements is a business problem called bankruptcy.

I urge you to stay away from a game whereby the insurance company will not negotiate your UCR prevention fees at 90% to 100%. You must walk away and not cave in on this point. The insurance company does not care if you go out of business; you can be replaced by someone else.

I would like to understand why dental insurance has maximums that put the customer on the hook (after $700 per child) versus maximums in medicine that put the insurance company on the hook after the max is reached? Is that insurance? Or is that a glorified discount plan? Does the medical loss ratios of 80/20 also apply to dental?

Insurance executives need to answer many questions from our profession before they tell us why we should partner with them. When I read the Patient Protection and Affordable Care Act (ACA) and see that something is a mandate with no benefits defined as compared with the very descriptive benefits for children's medical plans and no penalties involved, I raise my eyebrow at what is going on here.

It's been a few years since the ACA was launched, and there are still no good answers to my questions. I'll ask any insurance executive to come onto this site and answer them so we can begin to open the lines of communication.

I hear a lot of jargon about wellness and prevention from insurance company advertisements, yet the payouts to professionals interested in prevention does not align with those catchy TV ads. It's time to put the people's money where their mouths are -- that's in our offices but on our terms, not the insurance companies'.

Jason P. Hirsch, DMD, MPH, is a pediatric dentist and public health specialist. He has been in practice in South Florida since 2002 and is currently building a new state-of-the-art medical management of caries and evidence-based orthodontic practice in Boca Raton, FL.

The comments and observations expressed herein do not necessarily reflect the opinions of, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.

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