Ive always wanted to serve lower income patients, and eventually i want to join/open a practice that accepts patients with medicare/medicaid. Unfortunately, i have not found a mentor in my community who accepts these patients, so i dont have a clear idea of how successful their practice is. Money is not the most important thing to me, i chose dentistry because i love it, but obviously i do have loans to pay off. So what can i expect to make in a practice that accepts state insurance? Is 200,000 feasible?
Realistic income in a practice that accepts medicare/medicaid patients
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The answer depends completely on the state.
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Have you considered working for an FQHC or NHSC? you may get loan repayment through them and you definitely can serve an underserved population.
Which states are the best for this?
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Looks like Delaware has the highest reimbursement rate in the US.
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Having worked in FQHCs in three states through the NHSC, I will be the first to say that Medicaid will almost certainly yield compassion fatigue and burnout in the long run. Better to find alternative ways to treat the underserved or provide charitable/sliding-fee care. Medicaid comes with a lot of red tape that many don't realize. Reimbursement is only part of the problem.
What about working in a practice that accepts medicare/medicaid patients in addition to other insurances? Sorry if this is a newbie question, im only a D2 and i have no idea about the financial side of things.
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even with my only experience in Medicaid being a month long rotation in public health, I could see how this could happen.
any suggestions on alternative methods to treat underserved populations?
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The answer is complex. Reimbursements are only one piece of it. Any state could have a budget problem and decide the way to makeup for the shortfall is to chop dental benefits from Medicaid. Usually adult benefits go first, then ortho, then the kids. So it's not a great business plan to rely on only 1 payer as your main financial source.
Many corporate or chain offices take it. If you work at one of those, you would probably see Medicaid patients.
If you mean private practices taking it, then it's definitely location dependent. Where I am, there are a handful of private practice doctors who take it alongside private insurance and cash patients. They're mostly good doctors who do good work. They all have various reasons of why they take it. You can message me if you want to discuss more.
Then there is the fire breathing dragon, the government. Since it's a government program, politicians sometimes unfairly go after our colleagues to try and make a name for themselves as being the hero who found and stopped Medicaid fraud but really there wasn't any fraud because these doctors were practicing with good intentions like you and not out there to "scam the system." States sometimes hire companies to do audits to find who is "over billing." These companies and the states play by their own rules. But if they want to go after you, then these are criminal charges. It's a real gamble, so that's why many doctors don't get involved in the first place.
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You can volunteer with a health center/FQHC and collect per diem. They'll cover liability (FTCA- bulletproof) for a dentist to come and treat their uninsured patients while their employee dentists treat the Medicaid/insurance patients. Otherwise set up a nonprofit practice or foundation and do charitable work under that structure on your own terms.
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And how good you are at controlling your overhead. And how fast you are.
Here in my state, you have to prove everything in order to get paid. For an occlusal filling, you have to show the clinical picture of the decay. For class II fillings you have to show bite wing radiograph. For endo (the state only pays for molar endo), you will have to show the final radiograph with properly filled gutta percha in order to get paid. For ortho, you have to show the study models that show the malocclusion is severe enough to qualify for free ortho treatment.
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Medicaid only pays me 15 to 30 percent of my charges. It costs me 70-75 percent of my charges just to meet my overhead. If I treat a Medicaid patient (or Medicare patient, for that matter), I am always funding over half of the care...and I never get paid.
And since you brought it up, I used to practice in Georgia, and there, I was a Medicaid "provider". Around that time, Medicaid issued a rule that decreed that any physician or dentist who was accused of Medicaid fraud could have their personal assets seized, WITHOUT DUE PROCESS, much like drug-runners could have their cigarette boats seized if they are caught running cocaine in the inter-coastal waterway. The government is not required to give these assets back.
I would occasionally see a pediatric patient whose parent would borrow their friend's Medicaid card for their child and present it to me. I always treated those patients, money or not, but if I treated that patient and submitted a claim to Medicaid, presto, I had committed Medicaid fraud.
Shortly after that ruling, I quit being a Medicaid provider, because the federal government could seize my assets as a penalty, which would then affect my family.
I now practice in Minnesota, and Medicaid here is called Medical Assistance (MA). The US federal government gives money to the state, and the state oversees/runs it.
In 2010, there was a $4 billion shortfall in the Minnesota state budget. The state legislature had to decide allocation of state funds to either medical/dental benefits for those in need, versus, say, road construction. To offset this budget shortfall (and presumably to pay for road construction and any graft), Minnesota MA cut dental benefits. Among other things, they cut ALL general anesthesia services to anyone over the age of 20.
As an oral and maxillofacial surgeon, I see a lot of patients over the age of 20 with infected teeth whom I cannot treat with only a local anesthetic. Anyone familiar with the Henderson-Hasselbach equation and neurophysiology can tell you this. These patients need general anesthesia.
Tough luck.
This is what happens when legislators (state and federal) and bureaucrats decide what health care you are entitled to. It doesn't affect them. They do not have to live with the consequences of their choices.
And since you brought it up, I used to practice in Georgia, and there, I was a Medicaid "provider". Around that time, Medicaid issued a rule that decreed that any physician or dentist who was accused of Medicaid fraud could have their personal assets seized, WITHOUT DUE PROCESS, much like drug-runners could have their cigarette boats seized if they are caught running cocaine in the inter-coastal waterway. The government is not required to give these assets back.
I would occasionally see a pediatric patient whose parent would borrow their friend's Medicaid card for their child and present it to me. I always treated those patients, money or not, but if I treated that patient and submitted a claim to Medicaid, presto, I had committed Medicaid fraud.
Shortly after that ruling, I quit being a Medicaid provider, because the federal government could seize my assets as a penalty, which would then affect my family.
I now practice in Minnesota, and Medicaid here is called Medical Assistance (MA). The US federal government gives money to the state, and the state oversees/runs it.
In 2010, there was a $4 billion shortfall in the Minnesota state budget. The state legislature had to decide allocation of state funds to either medical/dental benefits for those in need, versus, say, road construction. To offset this budget shortfall (and presumably to pay for road construction and any graft), Minnesota MA cut dental benefits. Among other things, they cut ALL general anesthesia services to anyone over the age of 20.
As an oral and maxillofacial surgeon, I see a lot of patients over the age of 20 with infected teeth whom I cannot treat with only a local anesthetic. Anyone familiar with the Henderson-Hasselbach equation and neurophysiology can tell you this. These patients need general anesthesia.
Tough luck.
This is what happens when legislators (state and federal) and bureaucrats decide what health care you are entitled to. It doesn't affect them. They do not have to live with the consequences of their choices.
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You don’t want to go down this road in a private office. If you want to run government programs, go through an FQHC. The few dentists who actually go to prison are for Medicaid fraud, and while you’d think you’d have to be a crook to commit fraud, sometimes the paperwork and processes are so backwards that you make an onset mistake that either costs you everything or puts you behind bars.
These programs pay diddly (unless you’re in an FQHC where they get paid 4-8X what the private office gets paid for an encounter). The no show rate is high, the reimbursement is low, the red tape is thick. In a private setting you lose money here, and you upset your patients who pay the bills because you have to double or triple book to make state assistance profitable so you’re not on time, and that’s one of the fastest ways to burn your practice down (don’t value your patients’ time).
These programs pay diddly (unless you’re in an FQHC where they get paid 4-8X what the private office gets paid for an encounter). The no show rate is high, the reimbursement is low, the red tape is thick. In a private setting you lose money here, and you upset your patients who pay the bills because you have to double or triple book to make state assistance profitable so you’re not on time, and that’s one of the fastest ways to burn your practice down (don’t value your patients’ time).
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The highest in California would be $550 as a contractor. If you work 6 days a week it's still around $170K minus taxes and such
But you have to be super fast and efficient - at least 30 patients a day
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If the states wanted to, they could make Medicaid participation mandatory in order to renew your license. Luckily this is not the case anywhere.
Where I am, Medicaid pays about 55% of my private case fee for a full ortho cases. For me, the main issue is not the poor reimbursement since brackets and wires are cheap and the office is already open with empty chair time to accommodate more patients. My issue is my reimbursements have not increased in over 8 years. When I started, I paid $8/hour to the lowest paid employees who were mainly high school kids that helped with a lot of stuff. We are now at $12/hour in the race to $15/hour for minimum wage. but the program has not increased my reimbursement for anything. So it's costing me more in overhead. At the same time, volume has grown so collections have grown with it so it's sort of balanced, but at some point it won't be. It's not a horrible program from a social standpoint here since both parents can be working and making money while their kids qualify for Medicaid because the income limits are higher in our HCOL state. So not everyone is a deadbeat that is on Medicaid as is the perception in other states.
Ironically, I see many children of employees of dental offices that come to me because their kids (and sometimes the staff members themselves) have Medicaid and my office takes it.
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The problem is not always monetizing medicaid and medicaid patients. Many successful business models are based on this. The problem is when they decide to clawback their money and you don't have the money to pay it back. Many medicaid mills are pump and dump schemes and the thing is, you don't want to be left holding the bag. Look up RAC audits. If you think your writeoffs are bad now, wait for a RAC audit and watch your losses "RACk up"
I framed my letter that says that my medicaid provider number has been terminated due to lack of claims submitted. I never want to be part of any government assistance program since it is typically a lopsided and asymmetrical power relationship. Someone's usually targeted during election season (every 2 years) and you never want to be that person. If you want to help people, volunteer for a non-profit. Don't do it by signing up for government assistance programs. Also, don't get fooled by medicare's "opt-in" or "opt-out", because there is a third option... don't do anything. "Opting-out" still means you're in that infernal bureaucracy of medicare. There's a propaganda campaign out there saying that "oooh they won't cover your prescriptions for medicare part D if you don't opt in or opt out". I don't know how they even think that's a scare tactic. If your demographic is mostly the medicare crowd, I guess that's gonna hurt you. If you treat ASA I/II 18-64 demo with minimal health issues, then don't get fooled. Then you got the whole balance billing issue too if you decide to take medicaid/medicare patients.
I framed my letter that says that my medicaid provider number has been terminated due to lack of claims submitted. I never want to be part of any government assistance program since it is typically a lopsided and asymmetrical power relationship. Someone's usually targeted during election season (every 2 years) and you never want to be that person. If you want to help people, volunteer for a non-profit. Don't do it by signing up for government assistance programs. Also, don't get fooled by medicare's "opt-in" or "opt-out", because there is a third option... don't do anything. "Opting-out" still means you're in that infernal bureaucracy of medicare. There's a propaganda campaign out there saying that "oooh they won't cover your prescriptions for medicare part D if you don't opt in or opt out". I don't know how they even think that's a scare tactic. If your demographic is mostly the medicare crowd, I guess that's gonna hurt you. If you treat ASA I/II 18-64 demo with minimal health issues, then don't get fooled. Then you got the whole balance billing issue too if you decide to take medicaid/medicare patients.
I used to work for western dental in California. You cannot make $200k per year. My guaranteed salary was $137,500 on 5.5 days a week, no doctor in my 8 office region ever hit bonus, saw 30 patients every day. Unless you do arrestin, bone graft, and find a way to do PFM crowns, because dentical only covers stainless steel crowns and patients almost always say “I only want whatever dentical pays for.”
What is the salary avg for FQHC?
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Depends on the area.
What I was referring to above is that FQHCs are paid more by the state than a private office would be to see patients receiving assistance from one of these programs.
As far as how much dentists are paid in an FQHC, the last survey I read that was nationwide was 147k. But that will vary by region. In general, the pay for the volume worked is very low in comparison to a private setting where dentists rarely work 40 clinical hours per week. So FQHCs are often good places to start your career, and then good places to end your career if you can find a slow one that's easy to work at, but they're not great places to work during the peak of your career (years 10-25).
Some FQHCs really lowball the new grads and they're not worth working in (offering 110k for a full-time dentist would be an example). FQHCs burn dentists out though so very few are able to complete the 10 years that would be required to qualify for PSLF.
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My buddy sees about 40-45 patients a day and averages a production of $5500/day. All Medi-Cal patients and doesn't cut corners. No RCTs, no crowns, just straight fillings, extractions and SSCs.
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40-45 pts a day is roughly 4-5 pts/hr assuming an 8 hr workday. You are on roller skates jumping between ops the entire day. He must be super efficient. Does he have hyg give anesthesia or EFDA place restorations?
With medi pts, I've heard there is a high cancellation rate, so guessing they are double booking as well.
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You're right in that patients cancel, so that's why they have to book so many. It's definitely doable, but its a young persons game tbh. No hygiene or specialized DAs as that would take away from doctor revenue
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pretty sure delaware requires 1 yr residency
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When you accept medicaid, it doesn’t mean that you will have an unlimited supply of patients and your appointment book will be full all the time. It’s very competitive here in CA. A lot of dental offices in CA accept medicaid; therefore, there are not enough patients for these offices to fill their appointment books. That’s why it’s important to keep the overhead as low as possible. With low overhead (low rent, fewer assistants etc), you still earn good income despite having a slow work day with a lot of no shows and cancellations.
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Interesting. I'm in California and i can tell you not too many places take Medi-Cal. The places that do are jam packed and doing well if they can manage it correctly.
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The majority of the dentists, who practice in SoCal, are Asians. Asians are hard working people and most of them accept medicaid. Both of my OS friends are Vietnamese American and they both accept medicaid. My GP sister accepts medicaid and her office only has enough patients to keep her busy 3.5 days/week, 4-5 hours per day. Since she has no more debt, she doesn’t really care. Both of the corp offices, where I work at, take medicaid and neither of them has jam packed schedule.
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Wow. Yet another reason why California is a huge struggle for new dentists.
In my area if you accept Medi you will be slammed, and I think the same is true of many other states as well.
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Yeah, there are corp offices everywhere and they all accept medicaid. To survive in CA, you have to keep the overhead as low as possible. It's actually not that hard to control your business spendings. Avoid using high tech gadgets and avoid talking to the sale reps. I've learned a lot from working for the corp offices.
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I have heard this but have not found it to be true for my active patients. Once they get approved for braces the kids are excited and the parents are thankful it got covered and they come to their appointments. They don't no show at a higher rate than the private patients.
The initial consult appointments do tend to no-show at a higher rate. We only book 20 minutes for those and I wouldn't hesitate to double book those appointments.
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Do you think that could be different in ortho vs GP practice though?
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Of course.
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All you had to say was SoCal and it makes sense. Both bay area and pretty much everywhere in socal is saturated so I agree with you on them not being busy with Medi-Cal. I'm in a different part of Cali with less population but majority of Medi-Cal so it works here.
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Fair enough.
If you want to practice in less desirable areas in CA (ie Modesto, Victorville, Bakersfield etc), where not a lot of dentists want to move to….where they lack all the fun activities and good restaurants, then why not just move to states like TX, FL (both with zero state income tax), Washington, AZ etc? What’s the point of making a lot of money but you cannot spend it because there are no fun places for you to go to spend it? I’ve met a lot of dentists who moved to CA because they couldn’t stand living in those boring states. They’d rather take a pay cut than living in other states. Everything in life is a trade off. In order to achieve something, you have to give up something.
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LOL. This is the most California thing I've read in a while.
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The beauty of California is 1-2 hour drive from the less desirable areas and you're in LA or the Bay (depends on how close too). So I don't mind living here with less traffic, less saturation and spend time traveling on the weekends to different parts to have a good time. If you make it work in Socal then more power to you.
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Like I said before, you have to give up something in order to achieve something. To make it work SoCal, I have to make some sacrifices….charging low fees, working as an extra assistant, working on the weekends, making my own ortho appliances etc. A day after I paid off my last debt (about a month ago), I decided to hire 2 additional P/T assistants to help me so I don’t have to work as hard. Without any more debt, I can afford the increase in overhead. I’ll be 50 in 7 months. It’s time for me to slow down. My manager is 55 yo…..when she’ll retire in 10 years, I will probably sell all my offices and continue to work P/T for the corp like what 2THMVR is doing right now.
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Yea i'm good off working on the weekends, especially at your age, but that's the SoCal life!
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Hey??? You callin Arizona a boring state? Come on man. We got dirt. More dirt. Dust. No water. 120 in the summers. Scorpions. Rattle snakes. Javelina. Fun times.
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Plenty of insurance hassles for kids, far less for adults.
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Insurance companies hire the brightest minds. Ivy league MBAs. Their whole goal is to limit payouts to increase ins. company profits. So easy to do this with orthodontics. Why? Because ortho tx is carried out over time. Usually 24 months. The insurance companies love this since it gives them more time to limit the insurance benefits to the patient and orthodontist. Most insurance companies do not give a one lump insurance payout. They break it into monthlies, quarterlies, semi-annualies. Some are good. Most are bad.
Front office forgets to file or improperly files the insurance for the patient. Some insurance companies will not honor the insurance benefit if after 6 months. Patient loses or changes their job ...... guess what? They do not get the entire insurance benefit (reason most insurance companies pay out OVER TIME). The ortho office then looks bad or appears greedy since that unpaid insurance benefit is now tacked onto the patient's portion of the bill. Of course most if not all dentists/orthos have it in the patient's contract that they (dentists/orthos, etc.) do not have a relationship with the patient's insurance company and that ultimately .... the patient is responsible for all unpaid tx. But we still look bad. Most think we messed up with filing the necessary paperwork.
I remember one instance that still revs me up to this day. There was this particular insurance plan that my office participated in that was really bad. Discounted our fees almost 35%. I had enough of this. Had my office manager call the insurance plan, file the necessary paperwork and cancel our participation immediately. Well ... a few months later we had a new patient come into our office who had this very insurance plan. We told them we were not providers on that plan anymore. We were out of network and quoted our FFS fee. They liked us and accepted our fee. (to my amazement). Towards the end of the patient's tx (quite complicated: 30-36 months, Herbst, appliances, impacted max cuspid, etc.etc.) .... father comes in and tell me that his original insurance company told him THAT MY OFFICE WAS STILL A PROVIDER FOR THAT INSURANCE PLAN. We called and sure enough ... we were listed as a provider. We sent our original paper work showing that we had formally opted out, but to no avail. Well ... the patient wanted a refund saying that we charged too much. We tried to be nice about the situation. We explained that their insurance policy (even though we weren't providers since the ins .co lost the paperwork only covers 24 months of ortho tx. This patient was treated for 30-36 months with various appliances. So we went back and re-calculated the fee. Charged their insurance fee for 24 mons (ridiculous low amount) and then added 12 additional months since their tx went longer than the 24 mons. Nope. Patient's dad said their insurance company said we could only charge for 24 months of tx. Meaning I was giving 12 additional months plus applainces FREE to this patient. I spoke directly to the dad. Explained how wonderful his daughter's outcome has been. I asked him to meet me halfway on the fee. Now normally I do not get involved in fee disputes, but this one REALLY PISSED ME OFF. The father would not budge. So I brought out printed paperwork on his insurance plan's description of the fees that I COULD CHARGE. As with most low fee plans ..... they nickel and dime EVERY procedure. With my FFS patients .... I have ONE fee for EVERYTHING. Need additional xrays, pano? No problem. We take them. No additional fee to the patient. So I explained all the tiny nickel and dime fees we would have to charge the patient since THEIR PLAN CALLED FOR THAT. These included retainer visits. He was pissed and walked out.
When you are getting a FFS fee .... I do not mind insurance companies. Anything less (discounted fee schedules) .... well ....you know what my opinion is.
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Hopefully the father didn't see your nice leased Porsche in the parking lot with the license plate "2TH MVR" and thought that was where all his money is going. A wise older dentist once told me not to drive too nice of a car for that reason as well as not too shabby for pts to be ashamed of you.
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This is where I get out my calculator, add up the fees, tell them what they owe and then book their start. People really trust their insurance company to look out for them. I don't have the energy to convince them otherwise. There are a few well known employers in my area where I prefer the patient come in with the HMO than the PPO plan offered by the employer because the HMO pays my office more than the PPO. And the HMO allows all the extra fees so it ends up being the same as the PPO fee for our ledgers. The patient actually ends up paying a little less out of pocket.
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Oh. I hear you. Those leased Porsches were during a time I was doing exceptionally well. This topic has been discussed many times. Some patients resent it. Some see it as you are obviously successful and must be a good dentist/orthodontist. I have a passion for all things automotive and most of my longterm patients knew this.
Fast forward to today. Working Corp. Some offices in less desirable areas. Yeah. I have a small sub compact suv that gets great gas mileage. I do not want to draw unwanted attention to myself. Not to the patients or the staff.
You present the fees?
I remember you said something earlier about being disabled and having an associate orthodontist.
I started out in a 100% FFS practice. But as every year went by ....more and more of my patients switched to those HMO/PPO plans. I don't blame them. Starts with their employer. The employer switches to these non-FFS plans to save money and the employees are forced to switch due to a lower monthly premium. I remember treating child A for a FFS fee. Then child B comes along, but the parents have switched insurance plans. The parents knew I was a good ortho, but money and family budgets rule. So I would go ahead and just charge their discounted fee to make the parents happy and keep them in my practice. I started to do this alot. Pretty soon ..... the economics of providing quality FFS tx at discounted HMO/PPO fees just does not add up. It's like having a Porsche dealership and selling VWs.
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Since I started my office from scratch, I have done every job in the office but no, I have a TC. But I use the calculator and tell her what fee to present. I did have to cover for her while she was on maternity leave last year and I wanted to scratch my eyeballs out putting together payment plans for $3000 or whatever amount. Yes I am disabled and the division of ortho duties is I handle the practice management, consults, emergencies, referral communication, and the bulk of treatment planning and my associate runs the clinic.
I think these days knowing about insurance is part of the headache of doing business. We had a family with an HMO plan come yesterday. Dad was present and agreed to start the child with full fee aligners and pays the downpayment. Today mom calls and is causing all sorts of drama with my TC, starting with a very obvious white lie to get a refund of dad's payment and then calling her HMO carrier to complain. HMO calls my TC, she explains everything, HMO agrees with my TC that we are following the rules of billing correctly and said she will talk to mom. We've already refunded the family but I have a feeling they will be back once they realize this is how it works.
I don't have any families with insurance that is not an HMO or PPO. I think they were called "indemnity plans" that preceded the PPO? Everything I read says indemnity plans are hardly offered anymore.
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Not to sidetrack this thread. How do you make sure that the child (or any other patient) is dentally cleared (by their general dentist) before you take the impressions for the aligners? In Corp .... we give the patients a form that needs to be signed by their general dentist BEFORE we take impressions. Just curious what private practice orthos do.
Especially considering you are working with alot of PPO/HMO dentists.
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This particular patient was referred by her dentist and I know this dentist would not refer someone until all other dental needs had been taken care of. Short answer for the others, I make the clinical decision on dental clearance based on my clinical findings, how they found us (referred by the dentist or self-referred) and their reported dental history (we were just at the dentist vs can't remember what year we may have seen the dentist). This is for kids. For adults, there are definitely more patients that I have to send back for dental clearance before we will move their teeth.