Insurance problems

[proline]

i've been shadowing a dentist at a private clinic, she explained to me, that she is making less money now with patients having insurance. She says insurance only covers a fraction of the cost of doing the procedure, and she has to make up the cost by seeing more patients. Is this common among other dental practices? If so, why aren't dentists fighting it after seeing what happened to the medical field?

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[djeffreyt]

It's not a simple subject, and a dentist doesn't have to subscribe as a provider to all insurances. The dentist in question was probably talking about the difference between the "old days" when everyone paid out of pocket and today where most people have PPOs or HMO insurance plans

to make it over-simple...

back in the day before most people had insurance, people usually had to come and pay for dental services by themselves out of pocket, so whatever the dentist wanted to charge, that's what the patient had to pay. basically, the patient could get reamed, and if the patient couldn't afford the service...oh well...bargain, go to aanother dentist, or live with the problem.

There were insurances back then, like Aetna and a couple others, but that was really about it.

Now there are hundreds of dental insurance plans, and a lot of people get some dental coverage from their work. Some people, like me, still have to pay for their own dental coverage. Most plans are PPO or HMOs. How that works is that the patient on the plan can only go to certain dentists who take the plans. The dentist agrees to take the dental plan at their office and in return gets referrals from the HMO or PPO of patients to their office (which is good), but the drawback is the dentist only gets reimbursed for treating the patient according to the Dental plans fee schedule 9which is usually lower than what the dentist would want to charge the patient normally).

So why don't dentists fight it? cause that would suck for the patients for one. If all dentists suddenly said..."I refuse to take any PPO or HMO plans and I will charge as much as I want to my patients." If the dentists boycotted guess who besides the dental insurance companies is hurt? all the patients who used to get dental work done for little or no cost to them. Now they have to pay out the ass again, and many probably couldn't afford it and the access to care problem gets way way worse.

Now some dentists don't take PPOs or HMOs and simply require the patient to pay. These dentists either require the patient to pay out of pocket or they take patients who have an "indemnity" plan. "indemnity allosws the patient to get dental work done by a dentist who doesn't normally take the PPO plan. The insurance will only pay the portion of the dental costs that it would normally pay to a PPO provider. The patient then has to make up the difference and pay the rest to the dentist. Some dentists do this, but not many since it means they don't get patient referrals from any dental insurance companies and have to work hard to get clients willing to pay that little extra. A lot of cosmetic dentists are like this since most dental plans don't cover cosmetic work anyway.

there's way more too it than just that, but it's a delicate balance between dealing with the insurance companies, and screwing over patients...

 

[proline]

thanks djefferyt for your thorough and informative response! I really need to learn more about these issues.

 

[djeffreyt]

yeah...that's the cimple version...there is way more to each part. but the best way to learn is to have to deal with it yourself...I've spent 5 years without my parent's insurance to cover me and only once had a job that gave me some medical and dental benefits...the rest I had to figure out by dealing with that crap myself...personally, I still feel like I'm getting screwed, especially since I just got a letter in the mail yesterday from my insurance telling me my premiums have been reviewed and will be increasing...again...for the third time in three years.

 

[Euphoria36]

i've been shadowing a dentist at a private clinic, she explained to me, that she is making less money now with patients having insurance. She says insurance only covers a fraction of the cost of doing the procedure, and she has to make up the cost by seeing more patients. Is this common among other dental practices? If so, why aren't dentists fighting it after seeing what happened to the medical field?

I definitely agree with djeffreyt. Insurance companies are a big pain and personally I feel things would be much simpler by cutting out that middle man. From my experience working at a dental office for the past year, I find it's really not that hard to make money. It all depends on the types of insurance companies you accept. The particular office I work at does not accept most HMO insurances as they don't pay well on the services rendered, and from all of the PPO insurances we accept, we are only contracted with one company. You also have to realize payments from insurances are all based on the individual subscriber's plan. I have seen patients who pay nothing out of pocket on treatments because the plan they are under covers all of the expenses. Ofcourse, this varies based on each situation.

For example, if we are speaking of basic services, such as fillings or extractions, its true that the insurance companies only pay a fractoin of the treatment (usually about 80% for basic tx and that's based on their fee schedules as djeffreyt explained), but at the same time the patient is aware that they are responsible for the remainder of the costs. So, either way, you will get paid. It all depends on how you choose to run your business. Though I understand what your dentist speaks of and I agree insurance companies are cumbersome to deal with and leave a lot to be desired.

Also, the payments that the insurance companies make are not just based on the plan itself, but also on the area the dentist is practicing in. If the office is in a high-end neighborhood where the overall head/costs are much higher to own a practice, then the insurance comany will have a higher fee schedule for that particular area than somewhere else.

If your other concern is in regards to limiting the patient pool by rejecting certain types of insurances, well it's true that in certain cases you do have to turn away valid patients. But again, in the end if your approach is to have a wealthy and successful business, then that's a small sacrifice to make as long as you have established patients that will continue seeking treatment from you. At the dental office I work at, we have new patients every week, we are not short of patients. It can work, you just have to find a balance that will satisfy how you want to run your business.

Personally, I am currently not covered under a dental plan because I find it much easier to take care of my treatments out of pocket. Actually, in my case, it's cheaper since I have good dental hygiene and really just go in for my 6-month cleanings.