Dental Insurance Reimbursement: Is it Worth It?

You're listening to the Phil Klein Dental Podcast Thanks for joining us. I'm Dr. Phil Klein. Are you frustrated with dealing with dental insurance companies and is accepting their fees even worth your chairside time? Perhaps you should be handling insurance companies differently. To tell us more about this essential part of running a practice is our guest, Dr. Dominique Fufidio. Dr. Fufidio is the CEO and founder and main coach at Fufidio Consulting Group, where she has pioneered a unique coaching offering, one focused on understanding the clinical aspects of the dental insurance claims review process. Before we get started, I'd like to thank our sponsor, Philips Oral Healthcare. This is a phenomenal company that helps you empower patients with innovative, evidence-based solutions that meet your patient's unique oral care needs. Philips Oral Healthcare's advanced product line features Sonicare power flossers, electric toothbrushes, and zoom whitening. To learn more, visit their dental professional website at philipsoralhealthcare.com. Dr. Fufidio, it's a pleasure to have you on the show. Thank you so much, Phil. It's always an honor to be here. Yeah. So we have another podcast episode that Dr. Fofidio did called Dental Insurance Claims Through the Eye of the Claim Reviewer. She was actually a reviewer in her previous life. She talks from her perspective about how it's important to understand the mindset of a reviewer and what goes on on a day-to-day basis, which will certainly help you handle your adverse determinations. Great podcast episode. I invite everybody to tap into that one. And as I mentioned in my introduction today, we're talking about dental insurance reimbursement. Is it worth it? Now, Dr. Fufidio, I've interviewed a lot of people over the years on this show and elsewhere. And a lot of KOLs, key opinion leaders, recommend to the dentists to relieve themselves of the restrictions, the encumbrances of working with an insurance company. So they're not... into fees that may not be adequate to really make a profit on some of the hard work that they do. And, you know, other key opinion leaders say, well, a dental office really needs to be tied into insurance companies in order to make sure that they fill the chairs every day. The question I'm going to ask you is, from your perspective as one that worked with dental insurance companies and also worked in the private sector on the other side, is dental insurance worth having? I have so many opinions on that. So you were explaining it sounds like in network versus out of network and dropping those those ppos those are what the key opinion leaders are really talking about and if you can do it that is the way to go and i'm happy to work with clients on how to get there i did establish my office as fee for service and it was hugely rewarding and lucrative and the types of patients that were coming in they really wanted the treatment that we were rendering now there is literature out there saying that adults that have dental insurance are more likely to go to the dentist but there is a difference between medical and dental insurance and there's a lot of there's a gap in the knowledge there where if an office is explaining the benefit of a dental insurance plan whether you're in network or out of network it's worth utilizing insurance but there's also models and office models where the patient can have dental insurance but you're not insurance friendly in any way where you may print off the claim form and give them the services so they can work with the insurance directly and i do have recommendations if the dentist listening to this podcast is practicing that way because there are certain types of claims such as multiple unit crown claims those may be flagged and actually have more resistance on a payment front and in the end only about seven or eight percent of claims are actually denied because they're not meeting medical necessity and that would be aesthetic reasons so as long as the provider's office knows how to do the appeal process and what to speak to about the nature of the treatment that was done your claims are more successful and i think that Getting the payment from the insurance company to offset the cost of dental treatment makes access to care so much more affordable, and you will see a huge reward in treating a larger population of patients. What about the compensation for the services? How has the compensation kept up from insurance companies to the practitioner regarding the fees that that office has been charging over the years? Yes, that's a very good question. And like you were talking about those KOLs, those key opinion leaders, the thought leaders in the industry, everyone is talking about how the maximum benefits have not been raised. There's a lot of literature out there saying that only a certain small percentage of patients that actually have dental insurance are exceeding their maximums or meeting their maximums annually. But a lot of the plans are selected by the employer and then options are given to the employee for them to enroll in their benefits and they may not the employer may not be selecting plans that do not have an annual maximum they do exist i actually did a video on this recently and i was surprised when i would see them in private practice and they were wonderful plans and those would actually function more like medical insurance where procedures were covered at a higher rate but of course there is a larger out of pocket for the patient to be paying for those insurance premiums So there are multiple options out there. Right. So as an expert in the field and you are considered an expert in dental insurance, it's a very niche knowledge base that you're working with here. And you teach it and you have a program at Fufidio Consulting Group. You can reach that website. And I'm talking to the listeners at Fufidio, F-U-F-I-D-I-O Consulting Group dot com. And you can get full training for your office through this training program that Dr. Fufidio founded and developed. So you really can't make a blanket recommendation to a dentist who may have been working in a DSO for a while. They've decided to start their own practice. You can't make that recommendation and say, hey, avoid the insurance companies. Start off fee-for-service. You'll be more independent. Control your own fees and your own destiny. It really depends on the practice, the mindset of the dentist, the patient base, right? I mean, there's a lot involved here. You are correct. And actually, the way that I would explain being out of network is to my patients when i was a fee-for-service office was a little bit of what you just described there i would say with a ppo dental plan you are free to go to any provider of your choosing now hmo is different but ppo plan you are free to come see me phil with your insurance plan however delta dental united concordia i do not have a contract with them where they are promoting me on their website and they are driving patients to my office and as a result i have not accepted a lower fee schedule in exchange for those marketing dollars that they're spending. That's how I explained it. And that conversation is largely dependent on the comfort level of the office. And I do get questions routinely from the community about figuring out what their message will be. And I'm happy to work through that with clients. Yeah. So it's a tailored strategy and maybe it starts off where they are involved with more dental insurance companies. And as they... move in a different direction or maybe they want to be a volume practice and they want lots and lots of patients coming in and maybe they want to be a more focused practice on one kind of maybe they want to do sleep apnea obstructive sleep apnea and focus on that with advanced restorative cases then maybe insurance companies are not you know a good match for them what would you say are some of the procedures and services that are absolutely covered by insurance companies Now I'm going to quote the insurance companies and say this is not a guarantee of coverage, but preventative services. Typically, those are the ones covered at 100%, but it can be 80% or 90%, sometimes subject to the deductible. There are the different categories of basic and major coverage. I'm happy to work through these with a client or even make a guest appearance on another podcast about this. But you will always charge your UCR fee if you're in network or out of network because we do want to be indicating to the insurance company. what your fees are in your practice and some laws apply to certain states about non-covered services there's a lot there so it's not an easy question to just answer saying what's usually covered at a hundred percent but i think that deductible is what gets patients because and offices because in medical insurance many times you're paying for things out of pocket until you reach your deductible and then everything's covered Dental insurance is more like a benefit plan, and it's very similar in the terms of the deductible to vehicle insurance, where it's almost a buy-in or a deposit you have to make to have access to your benefits. Now, there is something else called high-tech laws and protection, and these would be for patients. And I want to bring that up because we're talking a lot about what can the office do, what can the office not do. There is a way of capitalizing on these high-tech, their HIPAA laws, where if something's not covered, you can still charge a certain amount to the patient whereas some states will say if it's not covered you cannot charge for it and that high-tech law is saying the patient knows that there is no benefit for that treatment but they're waiving their right to using their insurance benefits so that way they can have the treatment and at the rate that you feel rewarded being reimbursed at? So that's a very complex question. And there are a lot of people in the industry that are very helpful with that if a client is looking for that. I have a lot of support from different experts across different parts of insurance because like you said, it is very niche. So if there's something I cannot help with, I know who to get you to. Yeah, it certainly sounds like there's a lot to know here. And if you're building a business, a dental practice, you really should have a good mentor. to get you started and moving in the right direction that best fits that practice. And that's what you do, which is really good. And we're really happy that you're on this program. So if a service is covered, why does insurance companies not always pay for it? Oh, yes. So that's what I love to talk about because I was a clinical claim reviewer. So that means I was looking at the claims. So yes, crowns may be covered at 50%. but it still has to meet criteria. And what a claim reviewer is looking for is, is all the documentation submitted supporting that there was medical necessity for that tooth needing that crown? I used to think that insurance was saying, hey, was the crown done? And then we'll pay for it. So I was submitting a postoperative x-ray with the crown in place, looks beautiful, saying, hey, insurance, I did it, now pay me. But that's not the case. We're looking at the preoperative x-ray, and I say the proverbial we because I'm no longer a clinical claim reviewer. but we're looking at the preoperative x-ray to say, what is the story to this tooth? Why was this tooth crowned? That's why I love talking about telling the story that the insurance company needs to actually hear or actually read. So that way you don't have to go through an appeal process and having a keen awareness as to what is actually being reviewed for will only help you in having clean claims and less appeals and getting reimbursement the first time around. Now, if a claim is denied i know we've talked about peer-to-peer discussions in or peer-to-peer phone calls and the right to use them in a former podcast i suggest that the listeners go back to that one and hear how to go through and execute that peer-to-peer review process because we've talked about great examples of endos that were calcified and it's just misconstrued on the x-ray and providing that critical and very valuable information to the claim reviewer is all that you need to get that claim paid for. So if a service is technically covered but insurance was not paying, yes there are things like waiting periods that cannot be worked around. That is a policy criteria that's embedded in the rules as to what claims will be paid out. It may just be that the documentation did not support it. And if you feel that that claim should be paid out, we just need to get the appropriate information to the insurance company to check the boxes. Right. Now, my last question as we wrap up this podcast, sometimes dentists will actually perform dental treatment on a patient. Services will be submitted to the insurance company. Then the insurance company downgrades the benefit. to a different treatment hopefully that doesn't happen too often but can you elaborate on that yes it is still happening some of these policies i call them no alternate benefit policies that would be the opposite of what you were just explaining where if you're submitting a claim for a crown and it does not meet criteria there is no remapping is what some insurance companies call it where they're remapping to a posterior amalgam or maybe a composite A lot of the insurance companies right now are saying, okay, if we are going to say this does not meet criteria for a crown because there's not enough substantial tooth loss, but it does have... areas of decay or a restoration needs to be placed will we allow an alternate benefit like you're saying remapping that to a posterior composite typically it's been a posterior amalgam but these insurance companies they do want to pay for benefits that are rightfully due to the patient so there's a lot of talk right now about if there is a remap downgrading being to a alternate benefit composite Now, this can be an alternate benefit for two or three surface filling. There's a lot of things that are just evaluating the claim and seeing how it fares up or compares to the clinical policy to allow those benefits. So doctors continue to treatment plan as you see fit. Insurance is not a guarantee of coverage. It's great when it can offset the cost of treatment, but by no means is it going to be completely covering dental treatment. It's kind of scary to hear that dental insurance companies are still using the term amalgam. I know amalgam is still being placed in people's teeth around the world, not so much in the United States anymore, but you're saying insurance companies still put that as a downgrade benefit as an alternative treatment. That's crazy stuff. Okay, so as we wrap up this one, tell us about Fufidio Consulting Group, where we could find you and... What are some of the things that you have that our listeners could take advantage of? Yes, like you had referenced before, the videoconsultinggroup.com is a great place to go and see what articles that I've written that I'm linking there. There's just wealth of information that I'm trying to distribute. I am taking my course materials and turning them more into a on-demand course. And I do have on-demand courses coming out with some media outlets. So subscribing to my newsletter will keep... the listeners, viewers, anyone that's interested in finding out more up to date and up to speed on where they can get the latest and greatest information. Thank you so much and have a great evening. Thank you so much again, Phil. If you like our podcast and want us to keep it going, please leave a review on your favorite podcast platform. Leaving a review is a fantastic way to support us and help others discover our show. We really appreciate your support. See you on the next episode.