Answering Questions about Insurance Coverage and Predeterminations

Why don't we like to send predeterminations?

1. It trains our patients to be insurance dependent

2. It makes us responsible for getting accurate info

3. It is a LOT of extra work

4 tips for answering questions about insurance:

1. Be confident. YOU are the expert.

2. The best way to gain confidence is to PRACTICE. It's awkward the first 50 times. And then it's easy the next 5,000 times.

3. Keep guiding the patient to the outcome YOU want - scheduling the next visit.

4. We have 3 lines of defense. Keep things simple and use them ONE at a time as needed. Almost always the first line of defense works. If that doesn't work, try the second. If that doesn't work, then try the third.

The 3 lines of defense when patients ask what their insurance covers

1. Tell them we don't know

2. Show them how to find out on their own

3. Ask them "What if..."

Here's how it works:

FIRST LINE OF DEFENSE: TELL THEM WE DON'T KNOW

PATIENT: Does my insurance cover that?

YOU: To be honest I can't tell you for sure. For other patients I've seen it covered at 0%, some at 50%, and some at 80% or more.

I know Dr. Schneider wants to take care of this as soon as possible so we can see you Wed or Thurs next week - which works better for you?

Another example, for things like basic restorative where we think the patient SHOULD have some coverage:

PATIENT: Does my insurance cover that?

YOU: To be honest, I can't tell you for sure. For other patients I've seen it covered at 0%, some at 50%, and some at 80% or more. These are regular fillings, so your insurance should cover them the same as the fillings you've had before. You just have to watch out for things like frequency and yearly maximums.

I know Dr. Schneider wants to take care of this as soon as possible so we can see you Wed or Thurs next week - which works better for you?

If you deliver this first line of defense with CONFIDENCE, about 80% of the time the patient will agree with you and go ahead and schedule the next visit.

About 20% of the time, they aren't quite satisfied yet and we have to move to our second line of defense.

SECOND LINE OF DEFENSE: SHOW THEM HOW TO FIND OUT ON THEIR OWN

PATIENT: Can't you send a predetermination? My old dentist always did that for me.

YOU: We CAN... but the best way to get the FASTEST and MOST ACCURATE answer is for you to ask your insurance company directly. You can do that by calling them on the phone, or going online. If you have your insurance card I can show you how to do that, and I can even tell you exactly what to ask them.

I know Dr. Schneider wants to take care of this as soon as possible so we can see you Wed or Thurs next week - which works better for you?

Again, about 80% of the time the patient is happy and the conversation is over.

But about 20% of the time, they still aren't quite satisfied and we have to use our third line of defense.

THIRD LINE OF DEFENSE: ASK THEM "WHAT IF..."

PATIENT: Well, I'd really like a predetermination ahead of time....

YOU: Ok Mr. Patient, let's take a step back for a second. Let me ask you a question - If we were to ask your insurance company, and if they told us that your treatment would NOT be covered at all, how would that change your plans?

PATIENT: Well you're right, I guess I need to get this done regardless of what the insurance company says. I'll just have to figure it out.

YOU: Great! I know Dr. Schneider wants to take care of this as soon as possible so we can see you Wed or Thurs next week - which works better for you?

Or....

PATIENT: Well if the insurance isn't going to pay for this, then I don't think I can go ahead.

What now?

OPTION 1:

Go ahead and send the predetermination. Even if you give in at this point, you've done an AMAZING job by going this far and you've eliminated 95% of predeterminations.

**** Make sure you book the next visit! ****

YOU: Ok Mr. Patient, if it's really important to you, we will go ahead and send off that paperwork.

In the meantime, let's go ahead and get you scheduled so we save time in Dr. Schneider's schedule. Worst case scenario, if your plans change, just call us and let us know. We can see you _____ or ______ - which works better for you?

OPTION 2:

STAGE or CHANGE the treatment plan.

YOU: Ok Mr. Patient, if that's the case then this might not be the best time for you to go ahead with all of this treatment. Why don't we help you prioritize and get the really important stuff done now, and then we can revisit the other parts later.

I know Dr. Schneider wants to take care of this as soon as possible so we can see you Wed or Thurs next week - which works better for you?