Sheri's Solutions: 'We have unlimited insurance!'

"I have unlimited insurance. You can do anything!" Have you heard this before? All I can say is, buyer beware. There is no such thing as a free lunch, and there is certainly no such thing as an unlimited dental plan.

I had met this future patient at my favorite market. He is one of the folks I come in contact with on a semiweekly basis. Since you never know where your next patient will be coming from, I gave him a card. When he found out I was a dentist, he started discussing his dental plan. "We can get anything," he said. "There is no limit!" Then, he started discussing his dental needs (in public, of course). After he was finished, he said, "I need to send my wife in to you. She has problems." Another red flag? Possibly. I had to wait for several weeks before his wife called the office to hear about her issues.

Sheri B. Doniger, DDS.

When this patient contacted us, she had a huge story. A little more than a year ago, she had several implants placed and an immediate upper removable also was constructed along with a lower removable appliance. When she had financial discussions with the office manager, it appeared the dental plan would cover more than $20,000 of dentistry. Her "remainder balance" would be less than $5,000. Do I hear red warning signals?

She proceeded with the dental care, only to find out her benefit plan did not cover anything beyond the extractions. This plan didn't cover implants or the bone augmentation that was also placed. The shortened version of the story: The woman has spent several hours in our office to discuss her options since five of her six implants have peri-implantitis. She did not want to return to the other office, which is now asking for money. What to do?

First of all, aside from the dental mess this patient is in now, she needs to be restored to health. She is unable to eat with her existing maxillary appliance that is sitting on implants without any fixation to the denture. We are working with her to start that process. Second -- and the most glaring issue -- is: Why didn't the previous dentist do a pretreatment authorization?

Apparently, a pretreatment authorization was completed after the entire case was complete. Oh, I should rephrase that: An actual claim for the entire service was submitted. It was denied. According to her, in theory, "all-paying plan": There is no coverage for implants or any services attached to these implants. So, the dentist who performed the work failed in one of the most important cardinal rules of patient management: The dentist did not complete a preauthorization but relied on the patient's word of her plan "covering anything."

Apparently, this plan does pay very well -- especially if you are "in-network," considering other plans out there have a much less monetary maximum. It is a rarity in the world of dental reimbursement. But, as those of us who accept dental reimbursement know, all dental plans are not created equal. Although a plan may have a large amount of annual maximum funds available, it is truly not "unlimited."

When new patients visit our office, we have a procedure to contact their benefit company. We have a list of standard questions to ask, including preventive schedule, examination limits, effective date, and out-of-network coverage amounts.

And, yes, we have only been able to receive "robo" responses from several companies to issue a fax of the employees benefit levels. When we are able to reach a real live person, many dental company representatives have complimented us on our thoroughness. It truly has saved a lot of time on the team's part, especially if the patient will not receive any benefit at our office. The benefit validation form allows us to insert pertinent information into the patient's record and have a conversation starter at the initial appointment.

After the new patient is dismissed and the appropriate data are entered into the chart, we generate two forms: an actual services and a predetermination of dental benefits. Both are mailed at the same time. We receive information back from the benefit plan, usually within three weeks.

We are then able to contact and notify the patient of his or her anticipated coverage and expected remainder balance, due at the time of restorative. With more extensive treatment plans, we will discuss financial arrangements.

The most cogent point is: We always contact the benefit company to both confirm coverage and have a starting point for monetary discussions. For those of us who do accept dental assignment, it is a very prudent way to practice. For those of you who do not accept dental assignment, you may have other ways of having the financial discussion.

Back to the tale of the implant patient, had a proper preauthorization of benefits went out to the dental company, a whole other scenario may be playing out at this time. The dentist would have had the opportunity to discuss other treatment options if the patient did not have the financial ability to pay for the plan that was denied by the benefit company.

Yes, a treatment plan should be between the dentist and the patient. We all know the reality: If a dental company denies a service, the patient is less likely to consider it. We have all had discussions with our patients about an alternative coverage and payment for an amalgam rather than the composite service that was performed. The benefit company is not always right, but it is going along with the contract the employer has designated for his or her personnel.

It is always best to preauthorize any future dental care, unless you are in an emergent situation. We know this small effort will enhance both communication and good will with patients.

Sheri B. Doniger, DDS, practices clinical dentistry in Lincolnwood, IL. She is currently vice president and president-elect of the American Association of Women Dentists and editor of the American Association of Women Dentists "Chronicle" newsletter. She has served as an educator in several dental and dental hygiene programs, has been a consultant for a major dental benefits company, and has written for several dental publications. You can reach her at [email protected].

The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.