Focus On: Insurance Benefits

Tom Limoli


Tom Limoli discusses the 3 parts of a patient’s plan and why you can’t have one without the others.

Q: What is this love-hate relationship between doctors and the dental insurance industry?

A: I believe no greater dichotomy exists in all the professions of healthcare than that of the love-hate relationship between doctors and the fiduciary responsibilities of today’s insurance-benefit industry. One provides the loving compassion expressed in the art and science of prevention and healing, while the other coldly enforces contractual financial provisions established by both themselves and their clients.

It seems that there is an entire subculture within the various facets of dentistry that seems focused on not only creating but fostering conflict. For example, earlier this year, one glossy publication depicted Joan of Arc battling dental insurance, while another portrayed the benefit industry as a masked bandit attempting to circumvent the long arm of the law. Either way, I think it is easy to see the love-hate relationship that dentistry has with the dental insurance industry.

Q: Considering the love-hate relationship, what should a doctor and his or her team consider as it relates to an individual patient’s insurance plan?

A: There are many perspectives as well as objectives when considering what to do with, and about, the patient’s plan. Individually, no matter how you want to interpret the patient’s insurance on whether you are in or out of network, you must acknowledge the 3 separate phased functions of the patient’s plan: (1) before the patient visit, (2) during the patient visit, and (3) after the patient visit.

Q: Why look at it this way?

A: In order to simplify and streamline the overall reimbursement process, each of the 3 phases must have its own distinct parameter. In separating the 3, we have to understand and respect the fact that no single phase can logically exist on its own without the supporting interdependence of the other 2. Yet, when we pull all the pieces together, we see that the administrative, clinical, and executive teams of the dental office are all interwoven into successfully identifying and managing the role of the patient’s insurance in a dental practice.

Q: Can you elaborate on these separate phased functions?

A: Sure, let’s take a closer look.

Before the visit: How did the patient approach the decision to inquire about an appointment with your office? If it was a referral from an existing patient, you did and have been doing it right. Now, look one step further: What is the relationship between that existing patient and the referral? Are they social network friends, neighbors, coworkers, classmates, etc? If they share the same employer, they probably share a similar benefit plan. If not, how did they did they decide to select the practice? We most often find “being on the list” or “finding out if you are on the list” is the driving question that initiated the preliminary point of contact.

During the visit: Dealing with the patient’s benefit specifics is easy and transparently automatic when offices realistically embrace the concept of “treat the patient and not their insurance.” In many ways, this can be easier said than done. Old habits are hard to break, but how often are offices calling insurance companies to ask patient-specific information concerning frequency limitations? Is this information being used for the purpose of diagnostic-based treatment or finances? It has to be one or the other. Making it both drives the patient to say, “I only want what my insurance pays for.” As far as treatment is concerned, the insurance simply requires that you code and bill them for what you finished, not what you started; not what you think you started; and not what the patient said they wanted. Code for what you finished. Finished means done.

After the visit: The patient reached out to the office. The appointment(s) took place and the doctor made a diagnosis. The various treatment options were presented. A treatment plan was accepted. The patient agreed to the total cost of care. The terms of payment for the accepted treatment plan were presented and accepted. The treatment was rendered. The financial ledger now reads $0.00. It is done.

Q: Do you find patients today are influenced by the decisions of their benefit plan?

A: Yes! Be it marketing or necessity, patients look to their benefit plan to dictate how they will proceed. In many parts of the country, where communities are controlled by dominant employers, participation in network is not optional. Now, bring into consideration the changing scope of what was, and currently is, defined as a doctor’s contractual relationship. As patient-driven healthcare decision making continues to increase, payers will develop more cost-saving network-within-a-network options to satisfy their clients.

A word of caution—do not fall victim to the manipulative “verbal judo” praised by some of the unethical teachers of practice management. Responding to a patient’s question by twisting it into a generic true statement in order to get the patient in the door to make an appointment has destroyed the public reputation of many a fine clinician. Telling prospective patients “we work with all insurances” is not truthfully responding to their questions. Your reputation problems are just beginning when the patient sees their Explanation of Benefits and realizes they would have saved money had they gone with an in-network dental practice. If one teaches you how to manipulate others, then he or she is probably manipulating you, too.

Q: What about the insurance?

A: Please allow me the courtesy of going on the record in stating that I am neither for nor against the insurance industry. To take a steadfast and partisan perspective in absence of understanding one’s own individual situation is both foolishly unwise and belligerently selfish.

Q: Any final thoughts?

A: It is simple: If you don’t want to be in-network with the plan, don’t join. If you are miserable being in-network with the plan, get out. If your market situation requires you to be in-network, sign up.

Call me so that you do not lose your mind and your overall profitability while being either in or out of network. It is my honor to be of service.

Mr. Limoli is the president of Limoli and Associates. For more than a quarter century, he and his team have served all of the many facets of the dental benefit industry. He can be reached at (800) 344-2633 or by visiting

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