Dear RDH:
I have finally had it, and Jerilyn Hanson`s article (April 1999 issue) convinced me to write this letter. As a hygienist who works for an insurance company, I am tired of the dental profession`s relentless "insurance company bashing" routine.
I have a bachelor`s degree in marketing. But after college graduation, I decided that I wanted to do what I truly love - dental hygiene. I went to hygiene school right after graduation, and it was the best move I could have made. I thank all of the hygienists at my school in Troy, N.Y. for instilling their strong values in me.
Immediately after school, I moved to Texas and began working for the leading insurance company in the United States. Perhaps it is out of ignorance that we are constantly criticized. Our company employs many dental professionals in our consulting areas, including 11 RDHs, 12 CDAs, eight general dentists, two oral and maxillofacial surgeons, one prosthodontist, and one periodontist. We are all using our skills and knowledge to help patients in a way other than in a traditional practice setting.
Ms. Hanson was quick to criticize, stating that we are "getting increasingly more ridiculous with the arbitrary decisions." First, our dental consulting areas, located in four states across the country, see approximately 10,000 "patients" per week (not even including those claims that are paid at the processor level and never referred to consulting). However, a typical one-dentist, one-hygienist practice only has about 100 or so patients to keep track of in a week. Of course, there will be inconsistencies due to sheer volume but we work our hardest to ensure that things stay consistent.
Perhaps Ms. Hanson did not know that many plans are selfinsured and that the insurance companies merely look at the claim/pretreatment to determine if the procedures are appropriate per the provisions and guidelines that the patient`s employer has set forth. The employer ultimately pays for the procedure and pays the insurance company a fee to look at the claim - regardless of an approval or a denial! So no, we would not "rather wait until the patient needs expensive bridges and other appliances before providing benefits," as you state. It is the employers who usually sponsor the benefits.
Another possible cause for our "inconsistencies" could be that the providers do not provide adequate information to review the claims. It is extremely difficult to review for a crown without a periapical, a soft tissue graft without a perio chart, or osseous surgery without a FMX and perio chart. We do what we can with the information provided. Sometimes that is nothing. It is quite frustrating, for all involved, including the patient awaiting treatment, when Dr. Smith`s insurance coordinator submits a periapical of #15 for a crown on #8. We must then request additional information. It is not "a stall tactic" as Ms. Hanson alleges. I do not enjoy letting my "pending" drawer overflow and delaying treatment for those patients waiting. If the information was submitted correctly in the first place, things would flow along much more smoothly.
At Ms. Hanson`s office, she keeps copies of "two different plans, from the same insurance company, with entirely different benefits." Well, good for her, but what purpose does this serve? If she were as well versed in insurance issues as she suggests she is, she would know that there are hundreds of different plan designs, each with different benefits available even with the same employer. This is not being arbitrary, Madame! The patient`s employer usually selects which plans it wants to offer and the employee usually chooses a plan at open enrollment. If Mr. Jones wants benefits for implants, he had best make sure that the plan he selects covers dental implants!
Keep your articles in your office, Ms. Hanson, about just how "ridiculous" we are. What you do not hear are the stories of patients who have appreciated what we have done. We have gone outside the plan sponsor`s guidelines to approve a procedure that is in dire need even though it is not even a covered benefit. We have bent over backwards to get something reviewed because the appointment is "tomorrow" and the provider`s office "didn`t know" that it needed to be preauthorized.
The next time you choose to "bash an insurance company" realize that we are educated professionals making educated decisions according to the guidelines set forth to us. If you feel the need to "remind the patient that we are the bad guys not looking out for the patient`s best interest," as suggested by Ms. Hanson, please do so. I apologize that you cannot see it any other way.
Stephanie Santoro, RDH, BS
San Antonio, Texas
