Following the paper trail

June 1, 1998
The original disco era was in its infancy when insurance first materialized in dentistry. Since the 1970s, dental insurance has increased the need for dentists and hygienists. Thanks to dental insurance more people than ever are seeking the services we provide. Dental insurance keeps our recall patients toeing the line.

Hygienists must stay current with the constant changes in dental insurance.

Cat Schmidt, RDH

The original disco era was in its infancy when insurance first materialized in dentistry. Since the 1970s, dental insurance has increased the need for dentists and hygienists. Thanks to dental insurance more people than ever are seeking the services we provide. Dental insurance keeps our recall patients toeing the line.

New patients come in after years away from a dental chair saying: "I would have come sooner, but I didn`t have dental insurance." Insurance has become nearly a prerequisite to dental visits. If insurance isn`t going to help pay, they reason, then they can`t afford an appointment. This is a tragic misconception in the public sector, and one reason why only 50 percent of all Americans seek dental care. Insurance should not be a necessity for people to obtain dental treatment, but, sadly, economics plays a role.

It is this very situation where our job to educate the public comes into play. We need to inform the public about the real expense of missed dental recalls, both monetarily (in the cost of extra work for root canals and root planing) and physically (in the damage done by caries and periodontal disease). Insurance or not, missed recalls add up to enormous losses for our patients.

As more employers offer dental insurance as a benefit of employment, more people will be able to afford dental care. With an increase in patients seeking dental treatment, and with insurance companies realizing the benefits of preventive dentistry, the role and function of hygienists in dental-care delivery will expand. This will be seen through various forms of insurance, most notably managed care.

Insurance often can dictate or direct our mode of treatment, which is not as bad as it sounds. Insurance can be hygiene-friendly. When dealing with a patient who has insurance, there are three important steps to follow:

Step 1- Design the course of treatment without consulting the insurance. Base your decisions on the patient`s needs alone and devise a treatment plan listing the best courses of action.

Step 2 - Cross-refer your treatment plan with what the insurance allows to see if insurance covers the treatment as designed. If needed, can it be altered to give the maximum benefit to both the patient`s health and his checkbook? Can a different ADA code be used that the insurance will allow, but will perform the same function as your original estimation?

Step 3 - Propose the revised treatment plan to the patient or both your version and the insurance-altered version. Explain your reasoning on which course the patient should take. In preparing treatment choices, we must be careful not to overwhelm the patient, but simply provide different options of dental care. Our judgment and instincts should be used with every case.

The second step is performed as a benefit for the patient. If we aren`t compromising patient health, then why not give them an option? Hygienists do this every time we offer fluoride. Many insurance companies do not pay for fluoride benefits for adults. This, we know is ludicrous. But if our patients refuse fluoride unless it`s covered, then our patients go without a fluoride treatment. That`s when the second step comes into play.

Those people whose insurance companies do not pay for fluoride treatment have insurance prescription cards. These cards let them have prescriptions at very low rates. Prescriptions include fluoride gel for home use. Bingo. The patient refused a $15 office fluoride treatment. However, he can travel to his pharmacy and get a prescription of Prevident 5000 for five bucks. Thanks to our clever thinking, he gets the fluoride he needs.

A patient comes in who doesn`t present with periodontal pocketing, but has what we`d call a "grunge mouth." So, first, you decide that she could really stand a couple of prophys to get her back on track. Next, you check her insurance. It will cover two cleanings in a 12-month period. Finally, you tell the patient her insurance will pay at 80 percent for both prophys (and bitewings and exam), but when she comes in for her six-month recall, she`ll have to pay for it herself. Then, if she stays on a six-month recall, the insurance will pay at 80 percent for each prophy.

Great. The patient`s happy because she`s using her insurance and you`re happy because she gets the treatment you know she needs. It`s a win-win situation when insurance can be used to afford patients the dental care they deserve.

Know the codes

Dental insurance is tricky business. As dental hygienists, even if we don`t directly file claims or handle charges, we must understand insurance codes. It`s important for us to know these codes so that we can charge for the correct procedures.

I won`t spend the time going over codes here. The world of codes is ever-changing. Remember when we used 4345? Now, it`s practically nonexistent. The insurance companies felt we overused the code, and now refuse to pay it. This is typical behavior of insurance companies regarding codes. If we actually use them, they are taken away from us. In our office, we can still use the 4345 code on Title XIX patients because it`s the only way to allow them to have multiple cleanings (first and second pros) if they don`t present with criteria for root planing.

We need to understand the American Dental Association (ADA) codes so that we can properly treat our patients to the best utilization of their insurance. We benefit, the patient benefits and even the insurance company benefits. Carol Tekavec, RDH, is an expert on insurance and has authored books on the subject and written columns in Dental Economics and various other publications. She is an excellent resource for continued understanding of the complexity of dental codes.

We benefit from knowing the latest information on dental codes because our patients will more easily accept treatment if the out-of-pocket expense is not high. When we make it cost-effective for our patients, they take care of their oral needs. Therefore, we more easily continue to perform our job by meeting our patients` hygiene needs.

Patients benefit because they obtain maximum use of their insurance. They feel the money committed to insurance should be put to use. If not, why have the insurance? Most want their oral needs to be met, but they want insurance to pay its fair share.

Insurance companies benefit from this arrangement because patients who do not care for their teeth usually have greater oral needs later. Following a regular recall schedule presently is a lot cheaper than root planing and perio maintenance years from now. This saves the insurance company time and money by cutting down on its work force for extensive filing and foregoing payout for expensive procedures.

Knowledge of codes also is important in saving your license. That story about the hygienist losing her license because her dentist filed periodontal scalings for pedo prophys is absolutely true. It really happened. And if it can happen to her, it can happen to you.

Learn the codes and know what your dentist is filing. It`s your right to see what codes he has filed for procedures you have performed. Use your ledger notes liberally. As added protection, when you`ve done a regular six-month recall prophy, write "1110," the ADA code for such a cleaning, on the ledger.

At our office, the ADA code automatically accompanies our explosion code in the computer. If we type in "A" for adult prophy, "1110" comes up as the completed procedure. Since we file claims electronically, whatever we enter becomes the submitted code. It`s up to each hygienist and assistant to ensure correct code entry.

In learning the codes we`re not only helping serve our patients with better hygiene, but also we`re saving our fannies. No dental board is going to accept ignorance as an excuse from a professional dental hygienist. They`re smarter than that, and so are we.

Patient payment options

There are three ways a patient may pay for dental services: fee-for-service, third party lenders and third-party prepayment plans.

Fee-for-service is a two-party arrangement where a fee is established and then paid for directly by the recipient. A dentist will determine that $45 is fair for a prophy, charge this to his patient and then the patient pays that amount per cleaning. Payment is expected the day services are rendered.

Lender agreements for payment of dental services can be arranged by each practice. In our office, we offer a no-interest payment plan with approved credit. The patient applies for the loan (through a financing company) in our office and we file for him. We receive 90 percent of the patient`s loan, up-front, as payment in full for dental treatment from the loan company. The patient then pays the loan company directly, which keeps 10 percent of the loan as its profit. It`s a practical arrangement for patients with extensive treatment plans and no insurance.

The third type of payment is through third parties with prepayment plans. That third party can be an insurance company or an employer. Dentists and patients are the first and second parties, while the insurance company would be considered the third party. The third party processes and pays claims made by the dentist for the patient. These third-party plans are beneficial because they cover groups of people, not individuals. The financial burden is on the group. Some individuals will have no dental needs, most will have few dental needs and a handful will have many dental needs. The economics work well for the insurance company.

Remuneration for prepayment plans is done by the usual, customary and reasonable (UCR) fee. The UCR is a fee based upon the amount that most dentists in a geographical area charge for a particular service. For instance, if 90 percent of general dentists in Plano, Texas, charge $45 for a prophy, then $45 will be considered the UCR for Plano general practitioners.

There are many prepayment plans. Some may include commercial insurance companies, health-service corporations (dental benefits as part of health-care benefits), dental service corporations (Delta Dental, et. al.), managed-care organizations and capitation plans. All of these are third-party payment plans.

We, as dental hygienists, need to stay current with the constant changes in dental insurance. Part of being professionals is that we research and investigate the diverse payment plans open to the public. In understanding our patients` payment options, we can better serve them and provide for their dental needs.

Since 1992, Catherine Anne Schmidt, RDH, has been a full-time hygienist, exposure control manager, office coordinator, and CPR instructor at Gentle Dental in Cedar Rapids, Iowa. Schmidt holds a bachelor of arts degree in communications from Southern Methodist University. This article is an excerpt from her book, "Not Just the Cleaning Lady: A Hygienist`s Guide to Survival." The book is available from PennWell Publishing for $29.95. To purchase the book, call (800) 752-9764. Or fax to (918) 831-9555.