Winning the Dental Insurance Game

If you sometimes find it difficult to interpret those confusing explanations of benefits received from dental insurance carriers, you are not alone! Do not beat yourself up over it! Just know that it will get easier, as you become more familiar with insurance carrier terminology. After all these years in the business, I still find it challenging, and even more importantly, fun!

Yes, you heard me correctly! I did say fun! I enjoy the game of it all. And it really is a game, no matter what anyone says. The rules of the game are established by the carriers, and they are ever changing! The object is to keep those dollars in the carrier bank accounts! They realize that often time's providers and patients will accept the original benefit determination as final, and that means they will not have to pay the claim. Take this scenario, and multiply it by thousands, and you begin to get the picture.

So, what we have to do as dental business professionals is stay on top of our game! And this process begins long before we have an insurance explanation of benefits in our possession. Bottom line: if we choose to accept assignment of benefits on dental insurance as a form of payment for services rendered, we have a responsibility to do certain things:

*From the initial phone call, cultivate the proper patient attitude towards their dental insurance. Let the patient know your practice accepts assignment of benefits from their insurance as a courtesy to them, but they are responsible for payment for services provided, not their insurance company.

*Gather the information necessary to accurately estimate benefits. That is, confirm every patient's benefits, and learn the key questions to ask to enable you to become familiar with their policy; what it covers, and more importantly, what it does not.

*Submit complete and accurate documentation with every claim, so there is no question about liability having been incurred. This will help minimize delays in payment of the claim, and help insure healthy cash flow/accounts receivable.

*Have a follow up system to track unpaid claims. I recommend 30-45 days, depending on the type of claim. (If the claim requires consultant review, often following up in 30 days is too soon).

*Have a conversation with each patient before treatment has begun to acquaint them with estimated benefits from their insurance plan, as well as their estimated out of pocket expense. Use these words, "based on the information we have received from your insurance carrier, we estimate your out of pocket will be...."

*Close every conversation with these words "We can in no way guarantee your insurance will pay exactly as estimated, but we will let you know if there is any difference after your claim has been processed by your insurance carrier."

*Then, print out the treatment plan, and include the message "Insurance is an estimate, not a guarantee of payment. Actual benefits will be determined by your insurance carrier at the time your claim is processed by them."

*Ask the patient, "What questions can I answer for you?"

*If the patient says they have no questions, then have them sign the treatment plan, to indicate that you have reviewed the estimate with them. This may come in handy later, in the unfortunate event their insurance doesn't pay as estimated.

Remember this: We hold the power to set ourselves up to succeed or fail, when it comes to dealing with dental insurance carriers and patients. Knowledge is powerful! And right up there with knowledge is communication. These two things determine the result. If we become more knowledgeable about dental insurance, and better at communicating with our patients, not only will our collections and case acceptance improve, but we will build long term relationships with quality patients, who will refer other patients. So, let us keep our perspective, and realize, we can and we will overcome this challenge!

(c) 2009
Warschaw Learning Institute.

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Winning the Dental Insurance Game