For Immediate Release
Date: Apr 18th, 2011
Contact: Dr. Dr. Doyle Freano
On Your Side, Not Your List
In 1997 I attended a seminar about improving my practice in all phases. It was mostly about how to do complete dentistry, but in the second day, the lecture began to focus on the business/people side of a dental practice. Pete Dawson, DDS was the speaker and after describing in great detail all the problems a general dentist could possibly face, including technical, staff, patients, time management, and insurance issues he summed it up by saying there was ONE THING that if we focus on improving that would make immediate and drastic improvement in our practice tomorrow!
He turned to the board and wrote in really large letters “YOU!”
That became a defining moment for me as a dentist and I was able to make some tremendous strides in my practice as a result.
This past spring, I had a couple other defining moments. First, I read in the ADA periodical about insurance companies beginning to set the rates on non-covered procedures as part of their contracts with dentists and employers. And the Virginia Dental Association was being inundated by dentists there demanding action in the courts and legislature to prohibit companies from controlling the fees charged on non-covered procedures. I couldn’t believe it and wondered how in the world that could be legal or fair.
Further, I saw a Delta Dental TV ad about oral cancer. The gist was that Delta Dental is informing the public that they are leading the fight against oral cancer in Kentucky. It is unclear from the ad exactly how they are doing it. I researched and found that some employers do purchase coverage to reimburse for oral cancer exams. However, I am certain that it was a general dentist, oral surgeon or physician that detected and/or treated every oral cancer last year, not an insurance company employee. I suspect Delta Dental may have sponsored an event for free cancer screenings, which is admirable, however it is still our profession that has truly led the fight in oral cancer detection and treatment . Employers that choose to buy coverage for oral cancer exams deserve some credit. But, Delta Dental just verifies coverage and transfers payment, that’s not exactly saving lives in my book. It just amazed me how much credit entities are willing to take from those who actually deserve credit for benefiting their patients.
The epiphany occurred when I had a patient needing a crown under the most obvious scenarios denied by Anthem. The patient has a very healthy mouth, but had decay under an existing 15-year-old crown that had a previous endodontic procedure. I removed the old crown, photographed the decay and cleaned it out, did a build-up and placed a new crown. I sent the x-ray and the photo and a post-operative x-ray and it was denied. I appealed and it was denied again (after five phone calls to finally identify the “independent dental consultants) because as the company dentist in California explained to me, “it has a poor prognosis”. And he insisted he could determine that long distance with just an x-ray without examining the patient.
Without going much further into that issue, which is under appeal again, it turns out a “dental consultant” working for an insurance company can, under contract and in compliance with Kentucky law, micromanage my care and judgment and deny a crown for “poor prognosis”. Of course, a root canal, buildup and crown are the prescribed treatment for a tooth like this and any tooth in that condition. I concede any molar with endodontic therapy has less than an ideal prognosis. But the patient had coverage for this scenario and everyone agrees molars with endodontic therapy require crowns to improve their prognosis, precisely why people want dental insurance. Plus, this lady wanted her tooth restored, not extracted and replaced with a bridge or an implant or left vacant. She is quite happy with her crown, but really confused as to why her company denied it. I am beyond outrage after having spent an hour and a half restoring her tooth and at least four hours trying to help her get reimbursed.
What I finally realized was just how far we have come down the road with managed care. Then, I asked myself how in the world this happened and is there anything I could do about it. By the way, I have always been independent of all insurance contracts. I have never been a participating provider and until recently, it never interfered with my practice at all. Most of my patients had coverage and we filed their claims and helped them maximize their benefits. I always recommended the care I believed was best for them and charged a fair fee for it.
Beginning in 2008, things really changed. My practice had declined for the first time ever. 2009 was worse still with a double digit decline. As I thought more, I realized that quite a few patients had left for participating providers. I always had a few, now it was a steady stream. So, I thought about joining a network. I read a few contracts and talked to some friends. Most weren’t complaining too much anymore, just resigned to dealing with it. However, every single dentist I talked with said they regretted it. They wished they could drop out of network and admired me for not ever giving in. However; something had to give and things had to change. I took notice that five practices in Fayette County had closed in the past 18 months, NOT due to retirement but due to financial struggles by some very fine dentists. Several bankruptcies had been filed. But, I remembered Pete Dawson’s advice again and decided to really work on ME…first.
What could I do? I started by re-evaluating everything and listening carefully. I talked to all our employees, re-emphasizing our core values. I insisted that we be very intentional in showing every patient with an intra-oral camera, every problem, every day. I made sure that every patient received a thorough exam by me at each hygiene visit. I used our interactive video system explaining every treatment modality recommended. I thanked everyone personally for continuing to be in my practice and letting me be their dentist. I asked everyone, when finished, if there was anything they wanted to talk to me about. Many people said yes. We talked. I learned more. I had become complacent and discouraged.
We decided to give away free at-home bleaching trays and materials to our patients as a thank-you. After all, it was on sale by supply companies and people might want something that they wouldn’t be willing to buy at the moment. I told them it was available to any of their friends, as well, who needed a dentist. I told them I wouldn’t give a new patient anything I wouldn’t give to a loyal patient and explained that we had room for their friends. Everyone left with business cards, a firm handshake and a thank you. I asked for their referral again. I felt good about it and it came from us. It was not just a negotiated discount to put me in a directory or on a list.
Additionally, I wrote everyone a letter about dental benefits whether they had coverage or not. I defined it (instead of the insurance company defining me) as benefits, not insurance. I used several analogies, but the one that resonated was comparing dental benefits to car insurance. I asked if my patients would buy insurance for car washes, oil changes or tire rotations. I asked them what if it covered 50% of new brakes and transmissions up to 1,000 dollars, annually. Or if they had a wreck and got a check for 1,000 dollars even though they had been covered for years and never used it?
We stopped calling dental benefits insurance because it is not insurance. I refused to demonize insurance companies and told my patients to thank their employers for offering benefits. I told them it made sense to purchase if they were in a group, had a family and could pay for it as a payroll deduction with pre-tax dollars. I told them it made no sense to buy benefits as an individual. One could never get more out of it than one put in, by design.
We offered extended payments through third parties for those who qualified. We did some free care and never refused anyone in pain or infection treatment to relieve it. I recommended complete treatment plans that I would want for me or my family to help me keep my teeth, gums and joints healthy for life. I staged care in phases and I raised my fees in 2010 because my costs increased. I used the best materials, including continuing to use gold instead of non-precious metals. I replaced amalgam with composite, porcelain or gold.
We told our patients without dental benefits to be glad we were not under contract with any insurance companies because that meant they did not pay more than someone under a plan did. Why should anyone pay a lesser fee because they had benefits through a job?
I told my patients with benefits who asked me why I wasn’t on their list that it was because I WAS ON THEIR SIDE! I promised to file their insurance, document and pre-authorize their treatment plan, but reminded them that the main reason things were not covered was because the employer did not purchase the coverage for it. Everything could be insured in life, but employers chose dental benefit plans to help them defray the costs for their employees and for them to thank their employers for it. I showed them copies of claims returned that had changed my procedure codes from composite resin (which they wanted) back to amalgam (which they didn’t) and ones that changed porcelain fused to gold to “cast crowns” instead, in order to cut the reimbursement. I taught them the value of precious metal and non-degradable materials for their mouth.
I told my patients my fees included my office, my equipment, my dedicated employees, our health care and retirement, new technology, continuing education and our combined ability and effort. It varied with the case and complexity, but was upfront, worth it, would work and would last. And, if there were problems, I would resolve them. Our lab technician was in Lexington KY. and he was a skilled professional and our fees paid him for his expert work as well. Many got to know him too.
I told the truth. I looked them in the eye. I shook their hands and thanked them, regardless of their decisions. And my practice grew again, about 9% even in a difficult economy. Without external advertising or signing insurance agreements, while maintaining my integrity. Most of my patients listened and stayed and some sent new ones my way.
Most important, I found my voice again. And I believe what I can do about these issues for my profession is to encourage you to find your voice, too.
It is our voices that need to be heard! Our professional organizations need to hear and speak for us and our patients. Our legislators need to hear and act in the best interest of the public. While insurance companies can sell benefits, we need to manage and deliver the care because we care the most. We devote ourselves to learning, mastering and performing dentistry. We are totally invested, physically, financially, personally and emotionally. No one can speak for us like we can speak for ourselves. And others will speak for us if we don’t.
We have the opportunity every day to speak to those who matter the most and have the most at stake…our patients. And they will listen because they trust us. I am convinced again, that if we work on ourselves, find our voices and speak the truth with conviction, then our profession will continue to advance and thrive for those who follow.