By Karen Davis, RDH, BSDH
Don't we wish we had a nickel for every time a patient said, "Wait, does my insurance cover this?" or "If my insurance doesn't pay for this, then I can't do it." I've always wondered who gives patients these scripts that seem to be almost universal. Perhaps it's just human nature-we don't invest in things we don't value. But what if there were ways to help patients value treatment beyond insurance limitations and their own objections?
This is what I call insurance freedom. Many patients have comfortably fallen into the belief that if their dental insurance plan doesn't "cover" a procedure, they automatically determine they don't need it or don't want it. For a moment, let's put ourselves in the position of patients, for example, about having nonsurgical periodontal therapy and wanting to maximize insurance benefits.
Jack visits his dental hygienist on Monday and during the routine periodontal screening discovers that some of his 3 mm pockets have progressed to 4 mm, and a few places around his molars are now 5 mm with evidence of bleeding tissue. The dental hygienist and dentist seem concerned and want to have Jack return for some extra periodontal treatment.
But nothing is bothering Jack. His teeth and gums don't hurt, so he asks a natural question, "Does my insurance cover this?" He's told that it depends on the plan. He asks how much it will cost to have this extra treatment. He is given an estimate of $850 for a couple of treatments of nonsurgical therapy. His gut reaction is to simply wait and see what happens. After all, nothing hurts. He leaves the dental office with the best of intentions to floss more and see how everything looks next time.
In some cases, when risks are low, this may not be a bad plan. But what if Jack's risks are elevated? I've found inclusion of salivary diagnostics to identify increased risks of periodontal destruction helpful for patients to take ownership and value a condition that frequently has few symptoms. But it's more than just a simple salivary test to increase patients' value for treatment. Let's look at several other components to assist patients in developing "freedom" about making wise health decisions, regardless of their dental insurance benefits. First, re-educate patients about what dental insurance is and is not.
Insurance was never intended to "cover" all the needs and desires of a patient, but rather to help defray the costs of dental care. Since annual maximum benefits are almost identical today to what they were 40 years ago, dental insurance today certainly cannot be considered complete coverage.
The word "coverage" implies complete or total. It certainly does not imply that a patient will need to pay out of pocket. All team members should replace the semantics "insurance coverage" with more accurate semantics such as "insurance assistance" or "benefits" or "reimbursement." When patients ask if insurance covers a procedure, this is an opportunity to educate them about what their plan will assist with or what benefits they can expect from their particular plan.
"You get what you pay for" is certainly applicable where dental benefits are concerned, but most patients don't correlate low-cost premiums with restricted benefits. Again, when patients ask if insurance covers a procedure, that is a great opportunity to tell them that reimbursement varies greatly depending on the type of plan their premiums support. Benefits can range from none-at-all to substantial, depending on the contract agreement between the employer and insurance company.
Secondly, let's consider how the patient is informed of his condition and the need for additional treatment. In many dental practices, dental hygienists probe patients' mouths in silence and give a summary of the results with a statement such as, "Well, Jack, everything looks good, but there were a few deeper pockets around the back teeth that we need to treat." In many cases, patients are informed of the need for additional therapy or periodontal treatment, but they have not seen or heard any evidence of a real problem. And again, nothing hurts.
Here are suggestions for excellent communication to create value and enroll patients into nonsurgical treatment when indicated.
Ask patients to listen for any sites measuring deeper than 3 mm, and any area that bleeds during the measurements, and remind them that healthy tissue doesn't bleed. When patients are able to hear all of their own assessments during their screenings, they immediately perceive a deviation from normal or healthy screenings and are open to hearing about solutions to improve their condition.
Give patients a hand mirror to hold in their lap during the periodontal screening and ask them to view sites that bleed easily compared to areas that do not. For this part of the screening, using an interdental cleaner such as a Stimudent or Soft-Pick to demonstrate areas where tissue bleeds easily versus using a probe is instrumental in patients not assuming it is the dental tool causing the bleeding.
Focus on the benefits. After gathering the data from the periodontal screening, sit the patient upright to review findings and discuss relevance to his or her own health. Patients not motivated to treat conditions because they have no symptoms need to appreciate the benefits of treating conditions before symptoms appear so they're motivated to move forward. Benefit statements help patients understand what's in it for them. For example, following periodontal screenings, patients should hear something like this to help motivate them to act:
"Jack, you will benefit from nonsurgical periodontal treatment that enables us to eliminate disease-causing bacteria and reduce chronic inflammation present in your mouth. We know now that bleeding gums and deeper pockets are evidence of chronic inflammation that contribute to bad breath, jawbone damage around your teeth, increased risk of tooth loss, and adverse effects on your overall health.
"You can benefit from treatment right away as your condition is in the early stages of development. We see the best results long-term with early diagnosis followed by early intervention."
Enabling patients to make wise health decisions, independent of insurance benefits, is easier when you're able to present clear objectives and prepare them for what to expect. Good communication is paramount to help patients separate their dependence on insurance benefits from their decision to proceed with treatment in the absence of symptoms or pain.
Here is an example of how to present a nonsurgical treatment plan to a patient typically reluctant to do anything insurance doesn't cover.
"Jack, in order to reduce the chronic inflammation present in your mouth and create an opportunity for optimal health, it will require two treatments of nonsurgical periodontal therapy. The objective will be to reduce the bacterial load present in these deeper pockets to a level that will be compatible with health.
"The fee for this type of treatment is generally around $850 to $900. This will include specific suggestions for products to integrate at home in order to achieve the best results. What we have found is that insurance benefits for this type of treatment vary greatly depending on the premiums and the severity of the condition. Certainly we will do everything possible to maximize any insurance benefits that you have. But unfortunately, we see a strong correlation with lower premiums and lower benefits, and fewer benefits when the diagnosis is early opposed to later as the risk of tooth loss increases.
"I understand that you may want to learn more about reimbursement of your particular plan before proceeding, but I want to encourage you to make a wise health decision that will benefit you long-term, regardless of insurance assistance."
Following this, you want to ask the patient for his input. Open-ended questions such as, "So, Jack, what are your thoughts about this?" or "What else can I clarify in order for you to make a good decision?" help expedite the communication process. Patients generally respond to these types of open-ended questions with their primary objections. If they're concerned about costs or payment plans, whether or not the treatment is necessary, or how much time it will take, they will respond with that. No matter what objection a patient raises, responding with an agreement statement, such as "I understand" or "I hear your concerns" keeps dialog open and often enables you to overcome their objections with solutions.
Capturing patients' attention by re-educating them about the reality of dental insurance, enabling them to hear and see the evidence of conditions in their own mouths, and focusing on the benefits of treating their condition prior to symptoms are keys to help patients have freedom from insurance dictation or dependence. I'm fortunate to be part of a dental team committed to implementing these strategies. But all patients should enjoy the freedom that's possible when they make independent health choices when dental teams promote "freedom for all" strategies. RDH
Karen Davis, RDH, BSDH, is the founder of Cutting Edge Concepts, an international continuing education company, and practices dental hygiene in Dallas, Texas. She is an independent consultant to the Philips Corp., Periosciences, and Hu-Friedy/EMS. She can be reached at [email protected].