Focus On: Third-Party Carriers

Written by Howard S. Glazer, DDS
0 Shares

Howard S. Glazer, DDS, ponders the relationship between third-party carriers and dental practitioners and their patients.

Q: Can third-party carriers be both a friend and foe to patients and practitioners?

A: The short, simple answer is yes! Unfortunately, all too many times, the third-party carrier (the insurance company) seems to act in an adversarial way to both the dentist and to the patient. We all know that insurance can be an asset in receiving treatment but may not be all-encompassing relative to the treatment indicated for a patient. And that is when the “foe” aspect arises, often causing consternation for the patient and the provider, and, in some cases, putting them at odds with each other.

Q: Why did you choose to discuss this friend versus foe concept?

A: As you know, I travel quite extensively lecturing on new products and materials. Many times I speak with my colleagues during breaks, and inevitably the subject of and questions regarding dental insurance, and how to handle claims and problems with carriers, seem to surface. When I decided to address it, ironically, I composed this as I sat in the county court’s room for potential jurors. As was explained in the instructional video, it is every American’s civic duty to serve when called. For certain, this is a system that is fair and has been unbroken, working overall in the best interests of all parties. The same cannot be said for dental insurance; namely, third-party payer systems.

For the purposes of my analogy, let’s call the patient the plaintiff as the one who is requesting coverage and/or reimbursement for dental services; and, the dentist is the defendant who has been asked to justify the need for those services and treatments he/she has and/or will provide to the plaintiff patient.

Q: How do you view the third-party process?

A: Unlike the judicial system, there is no judge to oversee the process and offer a Solomon-like rationale for the outcome of the insurance claim. Consequently, claims are subject to what seems an arbitrary decision by a clerk who is reviewing the claim and trying to follow the “law” or rules of the insurance policy. At times, an “expert” consultant may be asked to review said claim and render an opinion as to the validity and/or necessity of the treatment. Unfortunately, the consultant will rarely consult with the treating doctor and therein lays an inherent flaw in the system of claim adjudication (more on that later).

Q: Do you participate with third-party payer plans?

A: At present, I do not participate with any plans. I have had a fee-for-service practice for about 3 years. About 75% of my patients do have third-party coverage, and we gladly fill out the insurance forms for them to be reimbursed. We do not participate with any insurance company. I did participate with a high-level plan, and during those many years, they had reduced the reimbursement schedule for reasons known only to them. A few years ago, they sent another letter indicating they would be, again, reducing the reimbursement so they could “remain viable in the community.” Guess what? I too would like to remain viable in the community. Expenses for my facility, supplies, and dental office team had risen thoughout the years and it was costing me more to stay “viable” and to be able to provide the quality of practice that I desired and that my patients had become accustomed to related to their care. That was the final straw; I resigned.

Q: Did you lose any patients when you dropped your participating status?

A: Yes. Initially some patients left my practice, but during the course of 12 to 18 months, about 70%-plus did return for care. That was a nice compliment and validation that our professionalism and quality of services provided won out over simply concerns of a monetary nature.

Q: What are some of the problems that you see with third-party carriers; namely, dental insurance?

A: To try to answer this question is to understand some of the inherent problems. I submit the following as the summation of the defendant dentist:

1. Insurance is not meant to cover everything. Patients do not necessarily understand this. After all, patients may have learned through their employer that “your dental insurance covers everything.” Of course, this is not true, as all policies come with limitations of coverage and maximum reimbursement amounts. The sole exception being direct reimbursement plans.

2. Insurance companies are not keeping up with the latest acceptable procedures in dentistry that can provide the best patient results. A common example is replacement for a single missing tooth. Most practitioners would agree that a single implant is now considered a more reasonable and healthier procedure (when indicated) than a 3-unit traditional fixed partial denture (bridge) or a removable unilateral partial.

3. Stop changing the codes! If an alternative procedure is suggested, have the courtesy to consult with me, the provider. I may have solid reasons as to why I did not think another treatment option was in the best interest of the patient.

4. Do not have clerks review my treatment plans. This is insulting. They are not dentists and not qualified to understand treatment rationale or order radiographs.

5. If the ADA has a code, it is often the “right dentistry.” The ADA has a great committee structure to include all specialties that are charged with creating and/or deleting codes that are relevant to proper patient treatment. There may be instances of possible alternative treatments, but one should rely on the practitioner’s best clinical judgement for having selected a specific procedure in a specific clinical situation.

6. Have a dentist consultant available to talk with the treating clinician. Dentists speak dentistry, and very often, the issue at hand can be easily resolved with a conversation related to understanding patient needs and what benefits the insurance company provides.

7. Pay for oral cancer exams. Let’s finally change the morbidity and mortality statistics for the better. Early detection is key. Screening exams, simple biopsies (eg, brush biopsy), and newer technologies (proven salivary biomarker screening tests, etc) should be procedures with insurance benefits to encourage earlier detection of oral cancer.

8. Do not request radiographs when they are not indicated just to validate the procedure and, certainly, do not request more than the specific tooth/teeth involved. Stop requesting full-mouth radiographs, as they are not indicated for a single-tooth replacement or even a 3- to 4-unit fixed partial denture (bridge).

9. Write the policies in plain, non-legalese English so that I don’t have to hire a person to interpret insurance policies. Language in all insurance policies is confusing to both the patient and the practitioner alike.

Q: You have presented some very interesting points. Do you have any closing statements?

A:The relationship between third-party carriers and the practitioner does not have to be an adversarial one. The verdict should always be in favor of what is in the best interest of the patient, within the limits of “reasonable and acceptable” practice standards. It seems my colleagues and patients understand this concept. Now, why can’t the insurance companies understand this concept?

Dr. Glazer, international author and lecturer, is a Fellow and past president of the AGD. He can be reached at (201) 224-2705 or via email at hglazer264@gmail.com.

Related Articles

A Mid-Decade Look: What’s Hot in Materials and Instruments

Single Crown Tooth Preparation: The 80/20 Rule

How to Build a Practice That’s Less Dependent on Dental Insurance