Inside Dentistry
December 2016
Volume 12, Issue 12

“When a service’s full fee is $100, but the participatory agreement says the maximum allowable charge is only $80, you did not lose $20 doing the procedure because you never had it in the first place,” Limoli explains. “Instead, you have to balance total plan collections to the percentage of chair hours sold to the plan. If Delta Dental patients are giving you 30% of your total revenue, then they cannot consume more than 30% of your total chairtime. The management answer is in your scheduled appointment book, never the operatory.”

The advent of electronic claims with electronic attachments—along with payer direct deposit—has shortened the average time of collections on claims from where it was 5 years ago. Collections on routine diagnostic and preventive services, as well as some basic restorative services, are between 7 and 10 days, Limoli says. With some participatory plans, it’s even shorter. However, out of network claims could be longer.

The good news is that technology has essentially allowed insurance claims processing and collections to take care of themselves. Doctors can go online, know exactly what’s payable and what’s not, at what rate it’s payable, and what the patient’s co-payment is. A relief to dental practice administrators, it will likely—in the not too distant future—enable nearly instantaneous payment of dental claims, particularly for in-network dentists, Limoli says. So, for example, a dentist could perform diagnostics, preventive treatments, or basic restoratives; the claim is filed; and the funds could be in the bank that same day.

Impacts of Legislation

Fortunately, the American Dental Association’s (ADA) Care, Access, and Prevention committee has spearheaded efforts to streamline the credentialing methodology when dentists join networks, explains Allen L. Finkelstein, DDS, chief executive officer of Bedford Healthcare in New York City and former chief dental officer of AmeriChoice/United Health Group. Not only does this alleviate insurance billing and coding headaches, but it also helps to remove barriers to care. With the ADA as a central clearinghouse for credentialing, dentists can provide all of the required information and identify the dental insurance networks they want to join. They can examine the fee schedule and determine which will be best for them.

“Rather than look at fee schedules that suggest what is or isn’t worth taking, dentists should look internally, see if they have down chairtime, and realize that the fee schedule is secondary to the patient’s care,” Finkelstein says. “If you’re not having production, then your overhead is just being divided over fewer patients. If you are productive, even with a lower fee schedule you can turn that into profitability.”

Although it’s simple economics, the manner in which commercial dental insurance benefits dentistry compared to how it benefits medicine is anything but simple. Finkelstein, a long-time proponent of integrated dental and medical care, says very few insurers have dental coverage in-house, instead hiring a third-party administrator or dental benefit manager to oversee coverage. This prevents a truly integrated healthcare coverage program that realizes cost savings to the medical aspect that are derived from dental insurance usage.

For example, patients who go to an emergency room for dental treatments—which are episodic and non-specific in nature—typically receive an analgesic for pain and perhaps an antibiotic. The outcomes are limited, and the care is not definitive. The patient will still need to go to a dentist for treatment, after having received a “dental treatment” that wasn’t actually a treatment at all, Finkelstein elaborates.

“When you build a model that combines dental and medical, we can start to look at those dollars and wonder why we are paying such high fees for a questionable outcome in an emergency room,” Finkelstein says. “The patient could have been treated in a dental office environment and have a more sustainable outcome.”

Overall, legislation with implications for the dental profession presents dentists and those in the dental industry with opportunities for changing behavioral patterns. In the end, they’ll be doing better for the public and themselves by making relevant and required modifications associated with such legislation as the Sunshine Act and the Affordable Care Act (ACA).

According to Finkelstein, the Sunshine Act is needed legislation that basically mandates audits and oversight. Similar to how healthcare providers gradually adjusted to Occupational Safety and Health Administration and Health Insurance Portability and Accountability Act compliance, adhering to the Sunshine Act is a matter of time and getting used to the requirements.

However, the most significant—and potentially profitable—behavioral changes in dental practice will stem from the impact that the ACA is having on dentistry. With the number of individuals now covered by dental insurance increasing incrementally state by state, dentists will need to become more efficient and focus their practices on value-based outcomes in order to benefit from ACA reimbursement.

All Things Considered…

Despite the economy and its implications for the dental profession, Behrendt asserts that dentistry is one of the most stable professions in the country. In fact, he says that only one half of 1% of dental lending notes in the United States fail, suggesting that it’s very difficult as a dentist to go bankrupt. Those odds are seldom seen with other small businesses, he adds.

“I truly believe that if your patients trust the care you provide, you live within your means, and you save your money, dentistry should be stress-free,” Margeas concludes. “I’m looking at practicing another 20 years not because I have to, but because dentistry is what I enjoy doing.”

The DSO Model

Over the past 5 years, dental service organizations (DSOs) that have focused on the clinician and patient have continued to grow and thrive, and there are now more than 1,000 DSOs throughout the United States. While some may not evolve to meet changing professional and patient demands and, therefore, not survive, it is clear that more and more dentists are finding success in the DSO model, observes Joe Feldsien, senior vice president of professional partnerships for Pacific Dental Services.

Among the reasons dentists may gravitate toward the DSO model is an ability to maintain their autonomy while benefitting from the support of a veteran operations team that understands what execution of the best practices of dentistry are, Feldsien explains. For example, DSOs are excellent at negotiating continuous improvement, which eliminates waste from day-to-day processes.

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