RE: [ACEsthetics] Insurance puzzle - your guidance and experiences..on biling combination or large cases to dental insurance

I don’t KNOW anything just as no one KNOWS what is going to happen with Clinton Care. Let’s go back to where it started and not who pushed it through. I just know there is no way that dentists can dodge this for eternity. We are already claiming to diagnose potential heard, kidney, pancreas, etc problems through chronic infection. We are treating sleep apnea, doing botox and sticking our noses in every niche we can that is now medical. OMFS are no longer oral surgeons. They are doing face lifts, facial reconstructions. We want to be physicians so it will happen. I quit calling it dental insurance ten years ago in my office and will not allow anyone else to call it that. It is a benefit or a supplement. Anyone who says they KNOW what will happen is an idiot. I say the odds are heavily in favor of us seeing our asses are part of national health care.

Guy W. Moorman, Jr., D.D.S.

The Swamp

Douglas, GA 31533

912-384-7400

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From: mchenry lee [mailto:drmaclee@gmail.com]
Sent: Tuesday, July 30, 2013 7:05 PM
To: John K. Hackbarth DDS
Cc: gmoor@windstream.net; safariandmd@aim.com; 'Dean Hutto DDS'; 'Jeff Rodgers'; 'David Boag'; 'Chris Hill'; 'ARUN NAYYAR'; 'acesthetics'
Subject: Re: [ACEsthetics] Insurance puzzle - your guidance and experiences..on biling combination or large cases to dental insurance

I agree John,

Guy, I don't sit on a hospital board so I don't have the background you do. Do you know that there will be dental insurance based on the medical model in the future or will it always remain just a benefit?

Insurance and benefit are two different animals. The problem that exists right now is the public is unaware there is a difference.

Mac

On Jul 30, 2013, at 5:26 PM, John K. Hackbarth DDS wrote:

Guy,

I know you and I have seen the encroachment of insurance and government in practice during our careers. BUT we need to be telling other dentists to fight the further erosion of our ability to practice as we please. There would not be any of the egregious insurance “plans” if we did not have enough stupid doctors signing up for them. Our profession need to be educated and industry and Uncle can’t force us to do what we won’t agree to.

BTW, there are not enough primary care docs, because they no longer make a decent living.

John Hackbarth, DDS

1708 Amburn Road

Suite A

Texas City, Texas 77591

409-935-2111 office

409-502-0681 cell

From: acesthetics@googlegroups.com [mailto:acesthetics@googlegroups.com] On Behalf Of Guy Moorman
Sent: Tuesday, July 30, 2013 12:11 PM
To: drmaclee@gmail.com; safariandmd@aim.com
Cc: 'Dean Hutto DDS'; 'Jeff Rodgers'; 'David Boag'; 'Chris Hill'; 'ARUN NAYYAR'; 'acesthetics'
Subject: RE: RE: [ACEsthetics] Insurance puzzle - your guidance and experiences..on biling combination or large cases to dental insurance

Mac, you and I can merrily go along saying we will do deal with any of these plans but if you are under 40 there will soon come a time when you will not be able to make a living without signing on for these plans. Right now the average GP dentist is making more than the average primary care physician. You think the insurance industry and Uncle is going to ignore that. I think not. At one time the primary care physician made the world turn and suddenly specialists ruled the world. Now we are going full circle and we cannot turn out enough primary care docs to touch the shortfall. That’s why you are going to see intermediate care clinicians explode. We have three nurse practitioners within fifty miles of me in private practice and two are blowing the doors off. We cannot continue to charge these 2000 dollar crown fees without attracting the government and insurance.

I’ve told the kids in my office that they can make as much money on 700 dollar crowns as they are making on the 1200 dollar ones but they are going to have to get faster and cherry pick good labs that are trying to find a way to produce quality work at a lower fee like World is with their changes in the corporate structure. I’m using certificates from other well-known labs to wee what quality I get from zirconia and e.max…it is good and I’m using that dreaded H and H technique. We are having a picnic now on ACE. ACE is not the real world.

Guy W. Moorman, Jr., D.D.S.

The Swamp

Douglas, GA 31533

912-384-7400

From: acesthetics@googlegroups.com [mailto:acesthetics@googlegroups.com] On Behalf Of Mchenry Lee
Sent: Tuesday, July 30, 2013 11:44 AM
To: safariandmd@aim.com
Cc: Dean Hutto DDS; Jeff Rodgers; David Boag; Chris Hill; ARUN NAYYAR; acesthetics
Subject: Re: RE: [ACEsthetics] Insurance puzzle - your guidance and experiences..on biling combination or large cases to dental insurance

The benefits of taking insurance is having warm butts in the chair, staying busy and maybe making a profit from the money insurance patients bring.

The cost of taking insurance and not being on any signed plans is having to hire one to two team members so they can stay on hold on the phone or take bitches about being screwed.

The cost of contracting is the same as above but 20 to 30% more for the discount which really just a marketing plan that cost 5 to 10 times more than most dentist allocate for marketing.

If you are a young dentist, is taking assignment or contracting something you want to do for the rest of your career? If the answer is no, what are you doing about it now?

Mac

On Tue, Jul 30, 2013 at 9:52 AM, <safariandmd@aim.com> wrote:

with some plans even if you max benefits you still need to charge contracted fees. that is the issue otherwise every dentist would accept insurance and do as you suggest.

Shahin Safarian DMD, MBA, LVIF | Irresistible Smiles
Carmel Valley/Del Mar 858.755.8993 | Chula Vista/Eastlake 619.656.6785
WEBSITE | FACEBOOK | LINKEDIN | YOUTUBE | THEBATTLEGUARD

-----Original Message-----
From: dean@drhutto.com
To: drmaclee ; 'Jeff Rodgers'
Cc: 'David Boag' ; 'Chris Hill' ; 'ARUN NAYYAR' ; 'Ace'
Sent: Tue, Jul 30, 2013 3:50 am
Subject: RE: [ACEsthetics] Insurance puzzle - your guidance and experiences..on biling combination or large cases to dental insurance

I am with you on this one Mac. At best, you will only get the maximum allowance of $1500 to $2000. So tell the patient, this is my fee. If we are lucky, I can get you a rebate check. In some cases I even tell the patient, if insurance doesn’t pay ,I will subtract it from your total. Just raise your fees to compensate for the adjustment.

Dean V. Hutto, D.D.S.

Aesthetic Family Dentistry

Phone: (281) 422-8248

Fax: (281) 428-8084

www.drhutto.com

From: acesthetics@googlegroups.com [mailto:acesthetics@googlegroups.com] On Behalf Of Mchenry Lee
Sent: Tuesday, July 30, 2013 9:24 AM
To: Jeff Rodgers
Cc: David Boag; Chris Hill; ARUN NAYYAR; Ace
Subject: Re: [ACEsthetics] Insurance puzzle - your guidance and experiences..on biling combination or large cases to dental insurance

Are there any insurance companies that are paying $19,800 for 22 crowns? Are there any Dental Insurance policies versus Dental Benefit policies?

Mac

On Tue, Jul 30, 2013 at 9:18 AM, Jeff Rodgers <drrodgers@drrodgers.com> wrote:

So lets say you do this as described.

Your case fee Mr. Jone is $44,000.

You have informed the patient that you are going to do this as 22 units at $900 ($19,800) and 1 unit of in-office whitening at $24,000.

Can we discuss the ethics of signing a contract saying you are going to do something for a fee, realizing you cannot actually do it at that fee and put food on your table so doing something through the back door in order to pay your bills?

If it comes to a deposition you will get hammered if you have to try and justify a $24,000 whitening fee for teeth that will be crowned. The real side of this is that depositions and testimony are not quite what you see on TV where you can find the one loophole that suddenly allows any and all behavior. There aren't really any Harvey Specters that can win anything. :]

But this is also coming from a guy that charges ~$1250 for a crown while the clinic down the road charges $599 or some such. However, when the patients leave they have a temp fee, anesthesia fee, HIPAA fee, room setup fee, custom color fees, etc and their bill ends up at around $1100. So clearly someone is getting away with a back door job on the system.

Regards,

Jeff

Jeff L. Rodgers, DMD, PC

www.DunwoodyDentistry.com
www.SleepDunwoody.com

Atlanta, GA

On Jul 30, 2013, at 6:28 AM, David R. Boag DDS <spikedds@gmail.com> wrote:

On Jul 29, 2013, at 7:33 PM, Chris Hill <chrishilldmd@gmail.com> wrote:

I would question the legality of that, David. That's one of those times that you say to yourself, "Self, if I was ever in court with regards to this case (be it the patient or the insurance company) how much would I be sweating this?" The lawyer in this case would be smiling and it most likely would not be yours.

Look, unless you are bound by contract, you can charge whatever you want to for your services. You have the right to charge $1,000,000 per crown if you like. It may be difficult to find too many takers, but the principle still applies. You are not legally bound. So long as you have a treatment plan signed by the patient, and they have signed informed consent, you have met your legal obligations provided you are not negligent or incompetent in your care.

Now in the case of a signed insurance contract, that is totally different. Break that, and THEN the attorney is smiling, cuz he's gotcha! You've got a lot more reason to sweat here, because the INSCO and their attorney's might be very interested in what you are doing, and they have a lot more $ to spend on attorneys than your patient does. You'll be sweating as the attorney makes you read the applicable paragraph that you, yourself, signed under no duress.

The nice thing about tooth whitening is that so far, I've NOT ONCE seen it covered by inscos, so it's a safe code to do this, especially in states where laws have been passed prohibiting inscos from limiting fees on non-covered procedures. My example was not to limit this to JUST that procedure--but technically it COULD be done with just that procedure. It is much better to do it over several non-covered procedures.

I would rather see lab upgrades,

Very often breaks contracts

999 codes,

Depending on how they are used, can break contracts. Usually require a narrative description and if you use one, you'd better actually DO what the narrative says and it better not be something covered by or bundled with another code.

interims,temps,

Most insurance contracts BUNDLE these with final restorations, so in many cases if you separate them out, you are breaking contract. However, if you have the patient in temps longer than 6 months, that code CAN be used, and sometimes is NOT covered by the insco, so this code would work fine in that case, and instead of having one HUGE charge you can divide the difference out amongst the units. Fair game. My example was to show the principle at work--keep it legal, don't breach contract, and charge a fair fee, but this certainly makes things look less outrageous, IF they are not covered.

Be VERY careful using these codes as you are suggesting, though. Many times these ARE covered procedures (and will have a fee limitation), and oftentimes, they will pay on one or the other (the temps OR the final), and if they deem the temp charge "not indicated"--just like ANY procedure which they deem is not indicated--you can, by contract, have the entire fee for either of those procedures legally owed back to the patient/insco.

Common example: You do S/RP on a contracted patient. They don't follow up with their recalls. They show back up 18 months after S/RP wanting their teeth cleaned, and they look like a train wreck again. The appropriate charge is for S/RP again. However, the insco likely has a two-year limitation on S/RP. You do it more than that, they deem this "overtreatment," and will require you to legally refund any monies collected for this procedure to the patient and to their company. They can do the same thing with any covered procedure so long as they can somehow justify an alternative. In this case, perio maintenance would be what they would say you can charge instead of S/RP. So you either do the entire case at a PM fee, or you can actually do a PM and NOT do the proper care, or you can refer the patient for perio sx. I have had this exact thing happen to me. Fortunately in my case, my patient actually went after the insco HARD, and got them to OK the S/RP, but I would never have been able to recover those fees without the patient's help. Never.

The same principle applies to doing crowns. If you do one on a tooth, and they don't see a reason (in their eyes) for the crown to be done, they will reduce the restoration to a direct amalgam, and you are stuck returning the difference to the patient & insco if collected.

When you use codes which ARE covered by the insco, you open yourself up to much more potential legal hassle. Try to stick with ones that are NOT covered. They are safer. Above all, have your attorney review your contracts before doing this. There may be precedent in your state for how these can or cannot be used. Again, some states have passed laws prohibiting inscos from limiting fees on non-covered procedures, and some have not. Check your state laws--or better yet pay a pro to do it.

diagnostics, etc.

Depending on the diagnostic, some are covered and some are not. Same principle as my above paragraph. If they are not covered by the policy, use those codes as well and divide the difference out amongst the many. For example, diagnostic casts are usually covered procedures. Often, so are orthotics. I'm not ,however, aware of a procedure code for use of a J7, although I am not well-versed at all on this diagnostic modality, but you could try that one if one doesn't exist. That could be one of the 999 codes that are not covered that could be justifiable.

And I would let your patient know that you are not submitting these things to insurance as they will not cover them anyways. Their insurance will most likely be eaten up after 2 crowns anyways.

And depending on your insurance contract, in many cases you are both BOUND to submit to insurance, or at least legally bound to hold to the insurance fee schedule for covered PROCEDURES even AFTER their annual benefits have been used. This is NOT true in all cases. Gotta review your insurance contract(s). And if it happens to be one where this is NOT true, you are set. You would then charge the insco fee for the first 2 crowns and then the elevated fees for the rest once benefits are exhausted. If it is true, you can't do what you are suggesting here without breaching contract.

The bottom line of my post is that if ALL of the procedures you are doing are covered procedures, and if the contract to the insco binds you to the allowable fee schedule even after annual benefits have expired, you are stuck, so you've got to find at least one procedure that is not covered and divvy up the remaining reasonable case fee amongst those charges to justify what you are doing while keeping within the bounds of your contract. This assumes you are in a state where inscos are prohibited from limiting fees on non-covered procedures. If not, tread VEEERY carefully. Quite honestly, I think you'd be a fool to do this yourself without legal counsel guiding you. CERTAINLY don't do what I'm suggesting wi based upon my advice alone. I'm not an attorney, and certainly not one in your state.

Be smart.

Ultimately, all this gobbledygook makes what Mac posted even more persuasive (not participating), but until a practice has enough cash flow, often contracting is a good idea. But then you'd better be a student of the game if you want to continue to do excellent dentistry like this within the bounds of insurance contracts.

David R. Boag, DDS

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