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Insurance Will Never Cover That: Navigating Dental Insurance Challenges Beyond Graduation
19 Plays10 days ago
About the Hosts:
Drs. Savanah Craig and Ronnetta Sartor are the hosts of "Beyond Graduation," a podcast that delves into the real-life experiences of dentists navigating the early years of their careers post-graduation. Dr. Craig is a practicing dentist who emphasizes the practical challenges and triumphs faced by dental practitioners. Dr. Sartor, also a dentist, shares her expertise and insights, particularly in areas concerning insurance and practice management. Both bring a wealth of knowledge, engaging in meaningful conversations that inspire and educate up-and-coming dental professionals.
Episode Summary:
In this engaging episode of "Beyond Graduation," hosts Drs. Savanah Craig and Ronnetta Sartor tackle the complexities of navigating dental insurance, a topic of paramount importance for new practitioners. This dialogue is both a refresher and an eye-opener, catering to those fresh out of dental school and adjusting to the nuances of practice management where insurance plays a pivotal role. As they unravel the intricacies of insurance narratives, coding, and patient communication, listeners gain insight into how these elements fit into the larger puzzle of running a successful dental practice.
They dissect the challenges dentists face when insurance coverage dictates treatment decisions. They offer practical advice on managing patient expectations and legal obligations while staying true to quality care principles. This episode underscores the distinction between in-network and out-of-network practices, shedding light on the operational and financial implications of each. Whether you're grappling with the daunting task of learning insurance coding or looking to shift your practice's insurance model, this episode provides valuable guidance to better equip yourself for the industry's demands.
Key Takeaways:
- The transition from dental school to private practice often lacks proper training on handling insurance, making self-education crucial.
- Mastering insurance codes and narratives is essential in defending treatment plans and optimizing billing.
- Communication with patients about insurance limitations without compromising on care standards is vital.
- Understanding the differences between in-network and out-of-network practices can significantly impact operational decisions.
- Leveraging intraoral photography and detailed clinical notes strengthens claims against insurance denials.
Connect with Us:
- Savanah Craig, DDS: @savanahcraigdds
- Ronnetta Sartor, DMD: @dr_sartor
- FutureDentists Beyond Graduation: @futuredentistsbeyondgraduation
- FutureDentists: @futuredentists
- IgniteDDS: @ignitedds and @ignitedds_coaching
- A-dec: @adecdental and https://www.a-dec.com/find-a-dealer
Dive into this insightful episode to navigate the convoluted world of dental insurance, fortified with shared experiences and expert advice from seasoned professionals. Tune in for more episodes that promise to illuminate, educate, and inspire budding dental practitioners.
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Transcript
Introduction to ADEC's Smart Start Program
00:00:00
Speaker
ADEC's Smart Start program offers first-time practice owners their deepest discounts on equipment and furniture for two years, plus other savings and complimentary services. Ask your ADEC rep for details and start smart with ADEC.
Early Career Experiences of Drs. Craig and Sartor
00:00:13
Speaker
Join Drs. Savannah Craig and Renetta Sartor as we navigate life beyond graduation. Real conversations about forging our own paths in our early years in our careers.
00:00:24
Speaker
There's a reason it's called practicing dentistry. All right, welcome back to another episode of Beyond Graduation. i am Savannah Craig and with me as always... I'm Renetta Sartor. Happy to be back with you guys.
Insurance Coverage and Treatment Planning
00:00:37
Speaker
so we are rolling on season out and we have been reaching out to our friends and followers and dental students that we know to try to get some topics that y'all want to hear about.
00:00:54
Speaker
um So shout out to Brandon from Lecom, just talking about some interactions that they have had in clinic, talking to some adjunct faculty about treatment planning and different treatment planning philosophies and what that looks like in dental school and in world outside.
00:01:20
Speaker
and So today we're going to be talking about how in Being told insurance will never cover that and what that might look like. Insurance is a big topic, but we'll try to cover it as best as we can.
00:01:33
Speaker
ah For sure. For sure. i think this is going to be interesting because the way that our our offices handle insurance is completely different.
00:01:43
Speaker
Absolutely.
From Dental School to Private Practice: Challenges and Insights
00:01:44
Speaker
But in addition to that, maybe we could rewind to when we were in dental school, not so much in dental school, but rewind to when we just left residency and started in practice and what that transition looked like.
00:02:04
Speaker
from not needing to really think about insurance to, you know, now this is a whole game that you have to to learn. And in school, we didn't learn anything about it. What was that, I guess, transition and experience like for you?
00:02:21
Speaker
i'm I'm glad that you said you didn't learn anything about it either because that has been my number one like fight. Coding is hard and I think we could have spent so much time in school going over insurance codes.
00:02:36
Speaker
We got a taste of it in residency. I think they had you know more – I'm glad that I had that transition because I think going directly into private practice with no insurance experience at all would have been very – overwhelming. But so learning how to code, learning about – so my practice is heavily in contract with a lot of insurance. So it's a very different ballgame than what I was used to playing.
00:03:06
Speaker
And arguably the biggest part or the biggest fight that I get in daily is writing insurance narratives or trying to explain insurance coverage to my team and my patients. And I don't.
00:03:21
Speaker
I don't know enough about it a lot of times. finding finding my office manager and being very grateful that they have a lot of knowledge and training about how, you know, you could – we could talk about this for literally the whole season.
00:03:38
Speaker
But yeah, it's it's super overwhelming and so unnecessarily complicated. Oh, yeah.
Understanding Dental Insurance: A Gift Card Analogy
00:03:45
Speaker
I want to, and you and I kind of laughed about this before, but when, you know, we both did the same program, but different years, of course. But in residency, one of our program directors always said that dental insurance It's different. It's not like medical insurance. Absolutely. In fact, think of it as a gift card or a coupon, but it's a gift card or a coupon that has stipulations on it.
00:04:13
Speaker
You only have x amount of dollars, but you can only spend it this way or that way. Oh, you need a crown? Okay, okay. you can only get 50% of the crown paid for with this gift card or coupon.
00:04:30
Speaker
And then you've got to pay the rest out of your pocket, you know, if that's so a good insurance, you know, so to speak. And so I think a lot of it is letting our patients know that, you know, we, we try our best to work with their insurance and everything.
00:04:49
Speaker
I was very much like you coming straight out of school. The group practice that I was in we were network with probably just about every insurance out out there.
00:05:02
Speaker
And so... What that meant is that, you know, insurance could say that they weren't going cover X, Y, z And sometimes it also means that if they won't cover it, you cannot charge the patient for it.
00:05:19
Speaker
it really You really have to, you know, if you are getting out of school or residency and you're joining a practice that wants you to go, you know, be become an in-network provider with certain insurance companies, know,
00:05:37
Speaker
It's important that you read those contracts with the insurance company to to know what you can and can't do.
Advice on Insurance Contracts for New Dentists
00:05:46
Speaker
and it's tough because you're joining an office that's in network with a lot of insurances, it can take a long time yeah to read through all of that and then recall, okay, this insurance does this and and that and so on.
00:06:02
Speaker
Yep. We had a ah patient the other day who... knew their plan, sort of. And she was like, I know that I get $2,000. This should cover this root canal and crown, you know, a plus B equals C. And we were like, yes, but your insurance only covers 60% of the crown and 60%, you know, whatever. And so it's not just this chunk of money that you can put where you want. And she was very upset about that. And we were like, we are also upset about that. I would love for you to be able to dictate you know what you do with this two grand that your insurance company gives you so that you and I could make this decision, but that's not the contract you entered into by accepting you know by with your employer, however you got this insurance.
00:06:52
Speaker
and And she was very frustrated. And I was like, I'm also frustrated, but this is the game. I had a patient this week and she's a school teacher and she's the sweetest thing. But she she said, you know, like, I know lots of things and I study lots of things. And she was like, for the life of me, I still cannot figure out this dental insurance thing like.
00:07:16
Speaker
You said me too. Yeah. I'm like, we all are trying to figure it out, but you know, it's almost like auto insurance, right? Or any type of insurance you can think of. I tell patients all time, if insurance can find a way to not pay, oh yeah, that's a golden day for them.
00:07:33
Speaker
Right. And so as as providers, pretty much, we almost have to play the game with them. And I mentioned being in network with insurances.
00:07:45
Speaker
So I also want to touch on if you're an office that is out of network with insurance, because that's a little bit of a different. So for a ah brief summary, and I'm still not the best at this, in network. Yeah.
00:07:59
Speaker
So ah for patients out there, for dentists out there, patients will call and say, do you accept my insurance? That is not necessarily the right question because even if you are in-network or out of network, you may accept their insurance benefits, right?
00:08:19
Speaker
Very true.
In-Network vs. Out-of-Network Practices
00:08:20
Speaker
So in-network for me, my insurance, office is in contract with these various insurance companies, which says we agree to their terms. They get to set the fees that we can charge for certain procedures.
00:08:36
Speaker
They get to set what they pay on those procedures, which may be different, which is one of the most confusing things. So for example, surgical extraction, say our fee is $300. Your insurance company, I don't know, for easy math, might say we pay $100 for that extraction or we we allow you to charge, I should say, $100 for that extraction.
00:09:01
Speaker
But then they may only pay you $90 for that. You know what i mean? Like it doesn't – it's not necessarily one-to-one. And sometimes depending on the insurance – You can then bill the patient for that $10.
00:09:13
Speaker
And sometimes you can't. And every everyone is different. Versus being out of network, which I would say most people that say their fee-for-service accept out-of-network benefits. Is that fair to say, Renetta? I think i think a there, because I was just on Facebook the other day and I saw people asking the question of what's difference between fee-for-service and out-of-network.
00:09:37
Speaker
I kind of don't want to get into that. Okay. Okay, that's another can worms. Because whole can of worms. Okay, all right. But think it's, I can speak for out of network because my now in office that out we are an out of network practice.
00:09:51
Speaker
Got it, okay. And so Savannah, you're right in that when a patient calls and says, do you accept my insurance? It means different things for your office versus mine, right? Because you guys have a contract with an insurance company.
00:10:07
Speaker
I do not have a contract with any insurance company. For our patients, we then ask them the question, do you know if your insurance allows you to go to an out-of-network office or do you know if your insurance provides you with out-of-network benefits?
00:10:28
Speaker
A lot of insurance companies, you know, do have that. And so the answer to the question when they call and ask, do you accept my insurance? The majority of the time, the answer is yes.
00:10:42
Speaker
It just means that I do not negotiate and the insurance kind company does not negotiate what the fee is. So if Dr. Renetta says that the fee for an extraction, like you said,
00:10:57
Speaker
is a hundred dollars, then insurance can't tell me that the fee is not going to be $100. They can, you know, they have their percentages of what they would pay on that.
00:11:11
Speaker
the patient then knows that, okay, whatever my insurance doesn't cover is my responsibility. Right. So in that same example, if the insurance company out-of-network benefits are $90 towards that $100 extraction, you can for sure bill the patient for that other $10. Right. And they do. it And so in my office, if that patient comes in, they'll pay the $10 on a day that the services are rendered.
00:11:39
Speaker
We will file the claim for the patient and the patient, not the patient, the insurance company will then send us a check for the remainder. Right. Right. Every insurance company does not do that. So that's a whole nother can of worms too.
00:11:54
Speaker
But I know that our Ignite DDS family down at LECOM, our LECOM men, they had specific questions about, you know, being told that, you know, when when you get out, you know, insurance won't cover that if, you know, it's not seen radiographically. you An example that Savannah and I have thought of is you have a crown on number eight and it's got recurrent carries, but you can't quite see it on a radiograph, but intraorally you could see it.
00:12:28
Speaker
Or if there's a filling on number 30 and you know the filling is breaking down, but you can't see it radiographically, but intraorally you can. So Savannah, tell me how you handle those situations in your office.
Digital Tools for Insurance Claims
00:12:43
Speaker
Yeah. So thankfully, we live in the world of ah digital photography. So your intraoral photos are going to be your best friend. And then the next best is detailed clinical notes on the day of the exam.
00:12:58
Speaker
For sure. For us. So as to the best of my knowledge, we send those claims to the insurance company with the radiographs, with the inter-oral photos, all of those things on the day we're saying, Ms. Smith needs a new crown on number eight.
00:13:14
Speaker
and We send as much information as we can at that first interaction with the insurance company. If they send back and say, nah, we don't agree. but we will then write narratives.
00:13:27
Speaker
And so we do spend quite a bit of time writing narratives to explain in more detail what was seen clinically and why this is a concern down the line and I try to explain to the insurance company what will happen if this is not treated.
00:13:47
Speaker
Hey, then you might end up paying for a root canal down the road or whatever because they're all trying to save money. The other thing that we are learning is a lot of insurance companies are using ai to look at those initial claims and try to...
00:14:03
Speaker
weed things out. A lot of that we can get into this whole SRP debacle because we're having a very hard time with SRP. But if your radiographs aren't clear in a way that the computer can read it you might just get the claim denied.
00:14:22
Speaker
you know what I mean? like There's not always humans looking at these things on those initial interactions. So appealing the claim, I think, in my experience, gets you to a human.
00:14:33
Speaker
quicker. What's your experience been? So I think you kind of hit the nail on the head, really. It's documentation. It's your note. It's all of those things. So 100%, just about anything that needs to get done or any issue we find with a patient in our office, we take an intraoral photo of. yeah And so when we file that claim to insurance, like you said like you said, pretty much my narrative is my clinical note.
00:15:03
Speaker
I send in my entire clinical note detailing what we saw intraorally, what we saw radiographically. We send the intraoral photo, we send the radiograph, as much information as you can seeing you do.
00:15:19
Speaker
But I think ultimately in dentistry, We have to get to a place where we also like explain to the patient too that, you know, just because insurance says that they may not pay for it or just because insurance won't, you know, won't pay for it does not mean that you need this treatment any less.
Communicating Treatment Needs to Patients
00:15:42
Speaker
Took the words out of my mouth. And so, you know, if you have decay, whether or not insurance is going to pay for the restoration, the decay is still there and it's still a problem that is going to worsen without treatment. in I know probably coming right out of school, it may not be an easy conversation to have.
00:16:06
Speaker
But you you you find a way to, you know, with compassion, let the patient know, hey, this is what I see going on in the mouth. This is the treatment.
00:16:18
Speaker
And I know for some patients, they really depend on insurance paying their portion to get insurance. it taken care of. But ultimately, i think as a profession, we have to get to the point where we aren't so relying on what insurance will pay.
00:16:37
Speaker
and don't be scared to like let your patient know what the diagnosis and treatment is based on whether or not insurance will pay. Because ultimately, you know our we take an oath to do no harm. And if we're not being 100% honest with those patients about what the diagnosis is what the treatment options are, and that means all of the treatment options and what could happen if it's left untreated, as well as what happens and risks and benefits of treating it, then we're not doing our job and duty as a dental professional.
00:17:19
Speaker
And a lot of times the conversation is – the biggest one that I am getting pushback on a lot of times is, you know, large restorations with recurrent decay and this needs a crown.
00:17:32
Speaker
And why can't you just place a new filling or there's a million scenarios. But letting the patient know, hey, you still – and it depends on the patient, right? Do I still believe you need this crown? Yeah.
00:17:46
Speaker
Yes. If we do not do the crown, we are at risk for fracture. You know, always tell patients, you know, insanity is doing the same thing again. if we already had a big filling and it's not being successful, why would we put a new big filling in?
00:18:01
Speaker
Some patients still just want that big filling and it's an ethical choice as you, the provider of, are you willing to do another large restoration?
00:18:13
Speaker
Is the patient really aware of the risks of doing that? Or is no treatment a better option? And sometimes that's a hard personal decision on what what you need to do. But the the not letting insurance tell you how to do your job is very tricky sometimes. It is very tricky. And I think it's why we see a huge wave of dentists that are trying to go out of network with insurance companies. Because it's almost like our hands are tied. Can be.
00:18:44
Speaker
Can be for sure. the For us, I think it also really depends where you're practicing.
Pros and Cons of Being In-Network
00:18:51
Speaker
In network, out of network, how of all of those things work. For us, being in network really draws a lot of patients to the practice. And I do think we are getting...
00:19:05
Speaker
Yeah.
00:19:10
Speaker
sometimes in dentistry i think we demonize the practices that are in network and there are games you can play to make it more lucrative and like i said we write a lot of narratives to fight for our patients but i'm not going to let them make me do substandard care for people either For sure. For sure. For sure.
00:19:31
Speaker
This insurance topic we could talk about for the entire season. So if you have any other questions out there about this topic in particular, please let us know in the comments because there are so many layers to this and not that we're claiming to be the insurance experts at all, but I think as a new grad, this can be a really big and confusing topic, but it's super important because it's how you get paid.
00:20:03
Speaker
how you make your money.
Conclusion and Social Media Engagement
00:20:06
Speaker
For sure. Super super important. Yeah, so definitely reach out to us and let us know what your experience has been with it or if you have any other questions.
00:20:17
Speaker
We hope that this helps. And as always, we will see you all next time. Thank you for joining us for this episode of Beyond Graduation. If you enjoyed this week's episode, be sure to share it with a friend.
00:20:33
Speaker
Connect with us on social media at Savannah Craig DBS and at Dr. Sartor. And remember, you are not alone on this journey. ADEC certified pre-owned equipment is a sustainable, affordable choice that makes genuine ADEC equipment available to every doctor.
00:20:50
Speaker
Each package is sold on a first-come, first-served basis. So if you see one you like, contact your dealer. For more information, go to www.adec.com backslash findadealer. Thank you for listening to Beyond Graduation brought to you by Ignite DDS and Future Dentists. This episode was sponsored by Ignite DDS Coaching. We build self-determined futures. For more information, please reach out to the Ignite DDS team.