what dentists need to know about running an insurance-less practice timothy f. kosinski, m.s.,...

What Dentists Need to Know About Running an Insurance-Less Practice

Timothy F. Kosinski, M.S., D.D.S., MAGDMaterial in this webinar is for reference purposes only. This webinar is sold with the understanding that neither any of the authors nor the publisher are engaged in rendering legal, accounting, investment, or any other professional service directly through. this webinar. Neither the publisher nor the authors assume any liability for any errors or omissions, or for how this webinar or its contents are used or interpreted, or for any consequences resulting directly or indirectly from the use of this webinar. For legal, financial, strategic or any other type of advice, please personally consult the appropriate professional

Material in this webinar is for reference purposes only. This webinar is sold with the understanding that neither any of the authors nor the publisher are engaged in rendering legal, accounting, investment, or any other professional service directly through. this webinar. Neither the publisher nor the authors assume any liability for any errors or omissions, or for how this webinar or its contents are used or interpreted, or for any consequences resulting directly or indirectly from the use of this webinar. For legal, financial, strategic or any other type of advice, please personally consult the appropriate professional

About Timothy F. Kosinski, M.S., D.D.S, MAGD

What Dentists Need to Know About Running an Insurance-Less PracticeDr. Tim Kosinski

www.ExecSense.com © ExecSense, Inc.

Dr. Timothy Kosinski is an Adjunct Assistant Professor at the University of Detroit Mercy School of Dentistry and serves on the editorial review board of Reality, the information source for esthetic dentistry, Contemporary Esthetics and Clinical Advisors, and became the editor of the Michigan Academy of General Dentistry. Dr. Kosinski received his DDS from the University of Detroit Mercy Dental School and his Mastership in Biochemistry from Wayne State University School of Medicine. He is a Diplomat of the American Board of Oral Implantology/Implant Dentistry, the International Congress of Oral Implantologists and the American Society of Osseointegration. He is a Fellow of the American Academy of Implant Dentistry and received his Mastership in the Academy of General Dentistry. Dr. Kosinski has received many honors including Fellowship in the American and International Colleges of Dentists and the Academy of Dentistry International. He is a member of OKU and the Pierre Fauchard Academy. Dr. Kosinski was the University of Detroit Mercy School of Dentistry Alumni Association’s “Alumnus of the Year,” and in 2009 received the Academy of General Dentistry’s “Lifelong Learning and Service Recognition.” Dr. Kosinski has published over 80 articles on the surgical and prosthetic phases of implant dentistry and was a contributor to the textbooks, Principles and Practices of Implant Dentistry, and 2010’s Dental Implantation and Technology. He was featured on Nobelbiocare’s Nobelvision and lectures extensively.

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Overview• With all the transitions occurring throughout medicine and dentistry, many

of us in the dental profession are straining to provide quality care for our patients while deriving an acceptable income from our practices.

• The American Dental Association is strongly advocating direct reimbursement concepts which may bring the dental profession back to a more conventional fee for service industry.

• Whether or not direct reimbursement prevails in the future, the notion of providing a good service at a fair price will always be a key to practice success. One method of accomplishing this goal is by developing and “insurance-less practice.”

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What to Know• An insurance-less practice is one that operates independently of any third party financial

reimbursement. Although payment is accepted from patients instead of their insurance company, arrangements can be made to minimize or eliminate any inconvenience that patients may initially anticipate.

• Once patients are assured that the practice will handle the paperwork required for reimbursement, and that payment may be made over a reasonable period of time, they are often willing to try this method.

• Once tried and successfully accomplished, fear of the unknown is removed and the relationship between the provider and the patient can proceed unimpeded. It has been the experience of one practice using this method that the greatest hurdle is that first experience.

• Many patients will need assistance in making the transition. A number of factors are important in developing a successful insurance-less practice, and these will be discussed

• With the difficult economy in many parts of the country affecting net income of the dentist, many of us are re-evaluating our practices and business goals and trying to find ways to do better in the uncertain future. Dentists need to look for ways to do things more effectively, efficiently and profitably.

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What to KnowDeciding whether the dentist should consider dropping participation with insurance companies, or going “non par,” is a difficult concept, especially for practices that have always participated with various insurance carriers, or provide HMO, PPO, capitation, Medicare and Medicaid care. Your main objectives for not participating directly with insurance companies need to be examined carefully. Do you simply want to raise your fees and be reimbursed at a higher level? However, simply dropping insurance participation may not necessarily raise your profits and other issues need to be considered. There may be a perception that going non par will allow the practitioner to create treatment plans based on the patient’s need rather than on his or her insurance coverage. The third party control over treatment can create negative issues for both the doctor and the patient, as the insurance company decides what is reimbursable and what is not. Yearly policy maximums need to be evaluated and considered. It is not unusual for a single crown and two “cleanings” to maximize the patient’s yearly limit. Possibly not participating with insurance companies allows the dentist to treat the patient’s needs as it needs to be done.

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What to KnowSometimes dealing with insurance companies can be overwhelming and a hassle. This may be reason enough not to participate. Dentists need to know their practices and their patient population. Non par practices often work best for established practices with solid patient relationships. These types of practices will sustain even after you stop taking insurance as payment for services provided. Going non par puts the burden for payment on the patient. The patient will get reimbursed directly by the insurance company and he/she will pay the dentist for services rendered. Is this possible for a new practice starting up. Often times some of the most relevant and dynamic treatment modalities, such as dental implants or cosmetic dental procedures are not covered by conventional dental policies. Even if they are, most patient’s policy limits minimize the amount of work that can be done and directly covered by the insurance company. A single implant could maximize the patient’s policy limit for the entire year.

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What to KnowThere is also much competition among dentists to attract and maintain quality patients, especially in the more urban large city areas. Not accepting insurance when your practice is in a small town may not be that big of an issue. Working is a metropolitan area where there are many dentists providing similar procedures may make the process more difficult, at least on the surface. It is critical that the entire dental team be on board with the concept of an insurance-less practice. Solid and precise collection policies must be in place. Going non par may result in an initial decrease in the number of patients coming into the practice. You will no longer get referrals from the insurance carriers. However, in areas where there are many dentists anyway who accept a particular insurance carrier’s policies, the number of new patients is diluted to all the dentists involved. Metropolitan areas allow patients to have more options concerning their dental needs, so it will probably be easier for them to find practices that accept their insurance as payment. However, marketing efforts may target those patients who may not have dental insurance coverage or need a lot of immediate dental care or that are looking for particular dentists with special skills.

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What to KnowLooking at your patient population’s economic status must also be considered. Some patients are looking for offices that provide services with the least amount of out of pocket expenses. Others may be looking to more innovative care. However, these two concepts are not necessarily distinct. You can still provide outstanding dental care and accept insurance. However, more comprehensive or extensive care will require the patient to have significant out of pocket expenses anyway. Co-pays need to be considered as those patients who are sensitive about co pays may be more difficult to convert to a non par situation than those who are not so concerned about co pays. The concept of an insurance-less practice allows the dentist to get reimbursed at their regular rates rather than by rates set by the insurance carriers. The rate charged by the dentists needs to be based on several things. First, overhead needs to be understood clearly. What does it cost to run the practice profitably. Second, the dentist’s income need to be determined. What amount of revenue is enough to make him/her feel financially comfortable. Working harder and working smarter are not necessarily the same thing.

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What to KnowIn the insurance-less dental practice the burden of payment rests with the patient. Filling out insurance forms is often not an easy proposition so it is recommended that the paperwork for reimbursement be filled out by the dental provider. Reimbursement will go directly to the patient, as the patient will pay for services directly to the dentist. It is the patient’s responsibility to pay for dental care regardless of what the insurance carrier reimburses. Follow up questions or complaints can be handled by the patient, as the insurance relationship is really between what the patient and the insurance carrier. The dentist had no discussion in what the policy cover or don’t cover, or the amount of reimbursement allowed. This discussion was between the patient, or the patient’s employer and the insurance company. What is covered is determined by the premiums paid by the employer to the insurance carrier.

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What to KnowNew patients in the insurance-less practice should be seen by the doctor first for a very thorough visual and verbal examination. No matter how thorough the examination, value cannot be perceived by the patients unless they can hear what is being said and thought.Intraoral cameras are especially useful for visual demonstration and for fostering a sense of personal responsibility in the patient. Once the diagnosis is made, all staff members should feel comfortable presenting dentistry. In the absence of the dentist, patients often direct questions or concerns to the chairside assistant. An educated staff may suggest or discuss various types of treatment. This is achieved easily and with sincerity when the staff is confident that the practice works consistently in the best interest of the patient.

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What to KnowMany patients will need assistance in making the transition to an insurance-less dental practice. In the ideal insurance-less practice, staff members are thoroughly interviewed, then hired only after passing a 60 to 90 day trial period. Individual performance reviews take place, as do staff meetings, morning (or daily) huddles, and clear and concise communication. Staff members are well compensated for their efforts. There are no automatic salary increases, offered instead are merit pay, incentives for overall office efficiency and increased revenue, and excellent benefits. Staff members are empowered by cross training and continuing education. Financial management should include an “open book” policy. Most of the expenses and revenues are shared with the people who produce that revenue. Of course there is always some information which is confidential, concerning personal, individual compensation programs.

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What to KnowPeople who have poor work ethics do not exist in an insurance-less practice, because every team member is vital and must maintain a productive role. It is imperative that the staff is comfortable with the quality of the work provided and the fees charged. Practice policies must be clear to all, and there can be no ethical issues to create discomfort. The type of staff a practice includes will greatly impact the success or failure of achieving this goal. What is needed is quality work by quality personnel under quality management. An educated staff, intelligent, caring team players who are in step with the practice’s philosophy, will play an important role in this process.

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Important Staff PositionsA scheduling coordinator, preferably a certified dental assistant with knowledge and experience in the clinical aspects of the practice. This person must not only be able to triage calls, anticipate potential delays, and be friendly and personable, but should also have sufficient background to answer brief, basic questions about dental procedures, and to plan time efficiently. Some knowledge of accounting is helpful for this position when ideal schedule planning is in effect, taking into consideration the weekly and monthly revenue. A financial manager knowledgeable about the many various methods of financing, including in house options, outside lending institutions, bank cards, and dental/medical credit companies. This staff member must be creative and flexible, and open to new options as they become available. She should also be confident in her ability to work within each patient’s unique financial circumstances, and should be empowered to make decisions necessary to finalize an agreement.

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Important Staff Positions An insurance coordinator is also important. The assumption that an insurance-less practice does not require an insurance coordinator is quite false. To the contrary, a staff member who is an expert in third party reimbursement is needed in such a practice. This staff member must be familiar with many types of insurance policies and must be able to keep up with the latest billing techniques and codes. Insurance claims must be handled promptly and efficiently to obtain and maintain the trust of the patients. Benefits counseling should be offered as needed, particularly in the late summer for those whose insurance companies use a calendar year. The insurance coordinator should offer to contact the insurance company to determine the remaining benefits for the year, so that any work needed can be performed before expiration of these benefits. On a daily basis, staff should be informed at the morning huddle of benefits available for each insured patient, so that any questions about availability of funds for unanticipated work which arises during treatment can be answered immediately.

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Important Staff PositionsAmong the duties of the treatment coordinator is to be aware of outstanding work that remains for each patient, in order to assist the patient with annual planning. The treatment coordinator should also be aware of the availability of benefits such as health care reimbursement funds and potential tax credits, as well as the type of work that is urgent, versus that which can be safely delayed. She must help the patient to overcome any obstacles to treatment, such as health complications, by maintaining communication with that patient’s other health care providers. She should be a professional with the ability to communicate with patients, family, and other health care providers alike. She should also be able to answer questions about the clinical aspect of treatment, in order to avoid delays created by the need to speak to clinical personnel before scheduling that work. She must make most other aspects of dental treatment nearly effortless for the patient, so that any minimal inconvenience created by direct reimbursement will be miniscule by comparison.

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Important Staff PositionsThe clinical staff members must be the highest quality personnel available, so that patients can observe the consistently high standards of the practice. Hygienists should possess, and demonstrate, advance skills in soft tissue management and dental implants, as well as in the prevention and early detection of oral cancer. Education in the latest techniques, sterilization, and OSHA standards is essential for all clinical staff, as is the confidence and ability to verbalize this knowledge when asked. All staff members should be active in continuing dental education and certified in CPR. The office and staff should be equipped to deal with medical emergencies and with special needs of the physically challenged, the mature adult, and the apprehensive dental patient. Lastly, chairside assistants and dental hygienists should be philosophically in step with the doctors and clerical staff in the insurance-less practice.

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Running an Insurance-Less PracticeMost of the marketing in the insurance-less practice is by that old standby method, “word of mouth.” Only 1 to 3 percent of gross receipts should be spent on marketing and/or promotions, and the practice must know exactly where the new patients are coming from. All new patients should be tracked, and a marketing plan developed and revised annually based on the previous year’s data. Most of the investment in marketing for the practice should be from internal, rather than external marketing. A high profile and substantial community involvement is helpful. Basic to the theory of an insurance-less practice is the individual plan tailored to each patient’s needs. High pressure sales techniques are not a part of the insurance-less practice. Instead, patient education, followed by joint decisions made by the patient and caregiver, develop the trust which is an essential ingredient to the formula. Schematic illustrations using computer graphics are useful in patient education. Using such a clear visual aid, patients are able to confer with family members as to the type of treatment proposed.

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Running an Insurance-Less Practice The financial coordinator is a very valuable member of the insurance-less practice team. His or her assistance is critical in gaining the trust and understanding of a patient accustomed to handling over an insurance card, expecting to eventually be billed for the balance. It is important to set up a financial agreement between the patient and the office that is separate and distinct from any insurance compensation. Interest free monthly payments may be offered to select individuals, or to any patient with default to a current bank card. Outside financing should be readily available for those who wish to extend payment over a long period, through several of the financing companies, such as Care Credit. It is also important to start collection procedures promptly in the event of delinquency to ensure continuing compliance.

Punctuality is very important to this type of practice, which places a high value on individual care. A patient should never wait more than seven minutes for a scheduled appointment. Patients today have busy lives, and expect the provider of a service to be organized and on time. It is common in this type of practice to have specialized scheduling days or times, such as pedodontic days when school is closed, surgical work in the mornings. Advance planning for best efficiency is a must.

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Running an Insurance-Less PracticeThe insurance-less practice team must understand the importance of repeat business. One person on the staff should be responsible for seeing that patients do not, “fall through the cracks.” The staff member responsible for continuing care is responsible for all short and long term follow up. If there are disgruntled patients or referral sources, that staff member must contact the person promptly. The staff member should be skilled in problem solving. Clearly, this person must be a person with good communication skills, particularly in listening, and a sincere desire to address each issue in the best interest of the patient and the practice. She should be in close contact with the financial coordinator in order to assist with any financial concerns or problems. Overhead in the insurance-less practice can be expected to be between 55 and 62 percent. It is imperative for this practice to be managed efficiently to ensure high profitability without sacrificing quality. This benefits both the patient and the practice. A balance must be achieved between accepting fewer patients and charging them higher fees on the one hand, and attempting to provide quality care for too many for too little on the other.

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What it Means for PatientsThe key to a smooth transition to an insurance-less practice can be found in the attitude of the doctors and staff. The reasons for the change to an insurance-less practice must be reviewed over and over with the staff. Everyone’s questions must be answered. All should understand why this transition is being made, and how it will benefit patients as well as the practice. It stands to reason that if the practice cannot convince itself that this move will be beneficial to all, it cannot possibly hope to convince patients. Patients will sense the comfort level, or lack thereof, and will respond in kind. The “bottom line” is that a practice must be successful to provide quality service to the community. As patients become more accustomed to seeing or hearing about the insurance-less practice, they may be more willing to give it a try. When dentistry is easy and convenient for patients, and the value of the services provided can be readily recognized, the insurance-less practice becomes a viable option among the many dental health care choices offered today.

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Payment Options for Patients1. Cash or check, providing a driver’s license and credit card.

2. Discover, MasterCard, Visa or American Express

3. Office financing up to five months for plans over $500. Monthly payments, no interest, a billing fee may apply. Current driver’s license and major credit card is required for prior approval and can be used as a default method of payment.

4. 50/50: One half on or before the first visit and the balance due upon completion. This method may be used for procedures requiring two or more visits.

5. Modified 1/3; One third to begin, one third in 30 days, and the remaining balance over 60, 90 or 120 days. This method may be used for procedures over $500 requiring three or more visits.

6. Six to 12 equal payments; One sixth deposit to be made at least 10 days prior to the first appointment, with subsequent payments charged to your bank card on file on the 24th of each month. Current driver’s license and current bank card with appropriate credit limit and available funds are required. This method is available for procedures over $1000 expected to require five months or more for completion. Billing charges may apply after six months.

7. Delayed start; Regular payments will be made until 50 percent of the total has been paid, then work will commence and three equal monthly payments to the office will be accepted for the balance.

8. If the practice is not contacted with the choice by 10 days prior to the appointment, we will assume that the patient has chosen the usual method of payment in full at the time of service rendered, by cash, check or bank card.

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Other Options to Consider

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Health spending accounts are another viable method of obtaining acceptance for extensive dental work from our patients. These are self insured private health service plan benefits arranged by employers for their employees. These accounts can be used to supplement insured private dental service plans or can be stand alone plans replacing traditional dental benefits. These funds are specifically allocated for particular dental spending such as orthodontics, dental implant, esthetic dental procedures. Flex spending accounts are used to pay for dental services which are not paid for by insurance. This can include co payments, deductibles and coinsurance. It may also cover expenses not covered by the dental plans. Often times there are caps on these types of plans or a time frame for eligibility in the health spending accounts. One of the major drawbacks identified with these plans is that the money must be spent within the coverage period as defined by the benefit coverage definition. Any money that is left unspent at the end of the coverage period, is forfeited back to the administrator.

Covering Extensive Dental ProceduresGenerally speaking, dental procedures that are considered “cosmetic” are usually not covered by dental insurance. Dental implants are just recently being added to benefits provided to patients with dental insurance. However, the amount of dental benefit is often so small that only some of the total cost of the procedures are covered anyway, and the patient will have out of pocket expenses. Cosmetic dental procedures are usually not preventative in nature and are instead meant to improve the esthetics of the smile. These procedures include; teeth whitening, implants, porcelain inlays, veneers, orthodontics, and cosmetic gum surgeries. Typical general dentistry procedures, such as simple fillings, teeth cleanings, crowns, bridges and dentures are normally covered by dental insurance but only to the pre determined maximum.If procedures are required that exceed the pre-described maximum benefit, then the patient must pay the balance. Many insurance policies today have a deductible or a co-pay for services rendered.

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Covering Extensive Dental ProceduresIn the insurance-less practice, as was described previously, the staff does indeed bill out the covered procedures to the insurance carrier. The big difference in the insurance-less practice is that the patient will pay for services up front via one of the payment methods already described, and will be reimbursed directly by the insurance carrier. This payment is normally prompt.

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Dental InsuranceThe benefits covered by dental insurance were negotiated between an employer and the insurance company. There are tens of thousands of dental plans and it is nearly impossible for a dental practice to know the details of each of them, and many insurance companies do not share the details with all dental offices. The patient is the only one who will have complete access to all the dental plan’s benefits. Insurance companies reserve the right to review all claims and make their own decisions on what to pay and what not to pay. This can be a very frustrating proposition for both the patient and the dentist. It may be implied that when an insurance carrier denies a service they know what is best for the patient more than the dentist does. Insurance decisions can be disputed, but valuable time is lost and payment to the dentist delayed. Managed care programs will often limit procedures provided to the patients by the dentist. These programs can provide a large volume of patients to a practice, but discount the payment made to the dentist. Also the choice of dentist can be limited by these plans.

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Questions & Misconceptions1. Is dental insurance really “insurance.” The answer is no. Insurance replaces what has

been lost, such as home or car insurance. If there is a fire at the house, and damage is done then the repairs are covered under your policy. Auto accident repair is covered by insurance to repair or replace the damage done. In reality, an employer negotiated a contract with a dental insurance company to provide a benefit to their employees. The insurance company’s responsibility is not to properly remedy the loss, but only to provide what is in the contract.

2. Dental insurance is a nice benefit, albeit a relatively small amount. Patients need to understand what they are getting. Once this is understood, conversion to an insurance-less practice is made easier, since the dentist is able to provide quality care and a fair price after careful deliberation with the patient.

3. What are direct reimbursement dental plans? These are self funded benefit plans, NOT INSURANCE, in which an employer pays for dental care with its own funds, rather than paying premiums to an insurance company or third party administrator. The patient pays the full amount directly to the dentist, then gets a receipt detailing the services rendered and the cost, which is shown to the employer. The employer reimburses the patient for a part or all of the dental costs, depending on the specific benefits described. For instance the employer may reimburse the patient 100% for the first $100 in dental expenses and then 80% for the next $500, and 50% of the next $2000, with a total annual maximum benefit of $1500.

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Questions & Misconceptions4. All dental insurance plans have limitations. The patient needs to understand this. There

are no “free rides” for the public anymore.

5. Patients are free to choose any dentist they feel comfortable with, and this is a tremendous advantage to those practices that provide quality care at a fair price and are not dictated by the restrictions made by insurance carriers.

6. As dentists, we are encouraged to evaluate the oral cavity to determine other systemic problems that may arise. As professionals, we are thorough diagnosticians who are an important part of the health care team. As our patients become more educated about the links between poor dental conditions and overall general health, they will seek out the best and brightest to retain their health.

7. Common fee for service Pros: payment of treatment is received when treatment is rendered, insurance companies do not dictate treatment options or a fee schedule, the patient’s ability to finish treatment plans is not determined by insurance benefit maximums, patients have the ability to choose their own dentist and the dentist has the ability to accept all patients, the dentist’s recommendations for treatment are not hindered by the insurance provider, and financing options are endorsed by the ADA and allow patients to pay over time.

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Questions & Misconceptions8. Common fee for service Cons: Payment required at the time of service may deter

some patient from going to your practice, transitioning from accepting insurance as payment to an insurance-less practice will often result in a loss of some of the patient base, offering financing options may restrict the practice by the ability of the patients to qualify for the programs offered, payments from financing programs do not reimburse the dentist 100% since there is a financing charge to the dentist of 5-15%, and finally there is no guarantee of a patient base. No company will recommend patients to you.

9. How many people participate in dental insurance? It is estimated that about 58% of the American population participate with dental insurance. 42% do not.

10.Dental insurance does not make sense for everyone. Some people are better off if they set aside a portion of their savings to cover both regular and unexpected dental work.

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Common Examples of Not Affecting the Patient

1. If you happen to fall down and break your four front teeth the insurance company may not cover any of your expenses because often times “accidents” are not a covered benefit. Medical insurance may step up and cover this problem, but that is a different topic. Also the yearly maximum of benefits need to be understood. No matter what the dental care that is required, the insurance will not pay more than the maximum which may be $1000-2000 per year. The out of pocket expense is still paid by the patient.

2. Insurance benefits often include 2 cleaning a year. If the patient requires more frequent hygiene visits, the insurance company will not compensate. Who is to decide the treatment your require, the dentist or an insurance administrator?

3. Many dental insurance plans have the same yearly maximum that they had in 1970. Most dental plans offered a $1000 per year maximum in 1971. At a 6% inflation rate that would be over $5000 per year today. In 1971 dental cleanings may have been $8, and the dental plans offered $1000 in benefits, but now cleanings are 10 times as much and the benefits is still only $1000.

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Questions That May Be Asked1. I am afraid of no longer taking dental insurance. Can I really do it? Absolutely.

Many of our most modern dental procedures are not covered by dental insurance anyways. You could create a niche within your practice that is insurance-less, that is, your cosmetic dental procedures or implant procedures.

2. Will I lose patients if I go “insurance-less?” The patient’s dental provider makes suggestions to dental practices that they can be treated with, so in essence the insurance carriers are providing you a certain number of patients. Many of these people may elect to go elsewhere, but those that appreciate your dedication and quality care will be willing to stay with you. Remember, you are still filing out the insurance forms and the patients still receive their benefits.

3. What do you consider to be the biggest benefit to being an insurance-less practice? I am able to provide quality care to my patients and am not dictated by the restraints of any insurance policy. I am able to do complete thorough , comprehensive treatment plans for my patients and provide care as the patient allows me to.

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ConclusionsInsurance coverage in dentistry is changing rapidly. Employers are no longer rushing to provide this benefit and if they do the financial benefit to the patients are limited.

Being able to provide comprehensive care under your careful direction without the limits of insurance dictates is rewarding.

As patients respond to an insurance-less practice and get used to the philosophy, the patients learn to understand the benefits of such a practice.

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what dentists need to know about running an insurance-less practice timothy f. kosinski, m.s.,...

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