Dentistry Uncensored with Howard Farran

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Dr. Charles Blair is dentistry’s leading authority on insurance coding strategies, fee positioning and strategic planning. He has individually consulted with thousands of practices, helping them identify and implement new strategies for increasing legitimate reimbursement. Dr. Blair’s extensive background and expertise makes him uniquely qualified to share his wealth of knowledge with the dental profession. A widely-read and highly-respected author and publisher, he currently offers several publications, Coding with Confidence, Administration with Confidence, Diagnostic Coding for Dental Claim Submission, Medical Dental Cross Coding with Confidence and the Insurance Solutions Newsletter. Also through his expertise, he founded www.practicebooster.com which optimizes insurance administration and aids in maximizing reimbursement. He holds degrees in Accounting, Business Administration, Mathematics and Dental Surgery. 

www.PracticeBooster.com 

Howard : It is just a huge honor for me today to have a legend on the show, Dr. Charles Blair. He's dentistry's leading authority on insurance, coding strategy, fee positioning, and strategic planning. He's individually consulted with thousands of practices, helping them identify and implement new strategies for increasing legitimate reimbursement. Dr. Blair's extensive background and expertise makes him uniquely qualified to share his wealth of knowledge with the dental profession. A widely read and highly respected author and published, he currently, for several publications, Coding With Confidence, Administration with Confidence, Diagnostic Coding for Dental Claim Submission, Medical Dental Cross Coding with Confidence and Insurance Solution Newsletter. 

Also, through his expertise, he founded practicebooster.com which optimizes insurance administration and aids in maximizing reimbursement. He holds a degree in accounting, business administration, mathematics, and dental surgery. He graduated from UNC Dental School ... is that where Michael Jordan ... didn't he go to UNC? 

Dr. Blair : That's right. 

Howard : University of North Carolina. Was he in your dental school class?

Dr. Blair : No, he wasn't but he was heck of a basketball player. 

Howard : Well, now, all these five books I just ... one, two, three, four, five, where can they buy those five books? 

Dr. Blair : Well, they can get them at practicebooster.com, practicebooster, one word, practicebooster.com, they can go to the store. Also, I have vendors that also handle the books such as Henry Schein, Patterson, Benco and some of the smaller dealers. So, basically, Practice Booster or from their dealer. 

Howard : From their drug dealer or their dental dealer? 

Dr. Blair : Their dental dealer. 

Howard : Okay. And are you on Twitter too? 

Dr. Blair : I am not. 

Howard : Okay. Because I ... Okay. So, it's pretty easy. Where did you get the name Practice Booster, boosting your revenue by billing more effectively? 

Dr. Blair : Yes. We're looking for a good catchy name and came up with Practice Booster to boost the practice and it could be from coding, it could be from fee positioning, it could be from practice management, a variety of things, but our Practice Booster suite of products, we concentrate on the coding, insurance administration and now, I've got a knock out medical cross coding book, it's 623 pages and it's a medical dental cross coding manual. So, we do have that and I've also added, Howard, myself speaking on medical coding out on the circuit. 

Howard : I wish you'd put a online CE course on Dentaltown on that. You ever thought about that? 

Dr. Blair : Well, I have to think about that. 

Howard : Well, if you want to, I think it'd be ... these [modules 00:03:00] we put up 417 courses and the views are coming up on a million. I mean the [inaudible 00:03:08] love watching at home. If they're on their iPhone, if they put up Apple TV so they throw it up on their big screen. 

Dr. Blair : Right. 

Howard : So, you can drink beer or eat popcorn while you're watching Dental CE. And I think the human mind ... but anyway, it'd just be an honor to have you put a course on there. Are these books on Amazon too? 

Dr. Blair : I think a couple of them are on Amazon but it's really ... they need to get it through our Practice Booster store or through, like I said, the associated dealers. 

Howard : So it'd be under resources then on your website? 

Dr. Blair : No, it's not under resources, it's under the store, S-T-O-R-E, store. 

Howard : Oh, okay. There, I see it. There, I see it. 

Dr. Blair : Yup. You got it? 

Howard : Okay. Oh, wow. Hey, [inaudible 00:03:58] stuff. So, start for these young millennials that just walked out of dental school. Talk to them about your journey. How did you go from dentist to the single number one authority on dental insurance coding, how did that journey happen? 

Dr. Blair : Well, I guess throughout my life, I've kind of climbed a mountain about every 15 years or so. And so, I got out of college, I went into navy, there for about five years and then, I went into dental school and was in private practice roughly 10 years. And then, the last 30 years or so, I've been in everything. I wrote the tax column with John McGill for about 20-25 years, on Dental Economics Magazine, solo dental practices, done a variety of things. And about 2004, a light bulb snapped and came on and said, "Wait a minute. This ADA list of codes in the code book is inadequate for most doctors, for all doctors and teams. They need more information." 

And so, I brought out my first Coding with Confidence book in 2004, and then, in 2010, picked up Insurance Solutions Newsletter, 2012, picked up or added the Practice Booster online. And then, in the last two and a half, three years here, we have added the book on insurance administration and also, the medical coding and that type of thing. So, I've really wrote out a number of just innovative products that are really desperately needed by the team and by the doctor. 

And the codes come out also, Howard, every year so every year, we got a new set of codes, there's also different interpretations. As you know, the PPO marketplace is changing. There's about 14 PPO plans sold now for each indemnity plan. So the name of the game is PPOs and downstream will be EPOs, that's an exclusive provider organization where the patient has to go in network. If they go out of network, they get paid nothing. 

Howard : What's EPO stand for? 

Dr. Blair : Exclusive provider organization, and that means that the employee must go in network. If they go out of network, they get zero. So, a lot of these doctors now have ... they're not a member, say, of Aetna, well, they've got Aetna patients coming in that are out of network and pay some out of pocket hopefully, just a few lattes but the EPO is going to be a disaster because they're ... if they don't go in network, they're going to have zero benefits, if they go out of network. So, that's one of the trends. 

We've got a couple of major trends in dentistry, one is the shifting sands to PPOs. Another one is the corporations, as you know, coming in and then, a third one is we're moving from a solo-type practice into a two and three-doctor more group practice. I think that we will see, particularly the formation of the two and three doctor practice, I think you're going to really see that accelerate in the next five years. 

Howard : So, you got out of school in '74 and I got out of school in '87, and we would just bill Delta a thousand bucks for a crown and they'd pay half, we bill them a thousand for a root canal, they pay 80%. Now, the PPOs are about, what, about 42% less than the indemnities? 

Dr. Blair : That's a rough approximation, yes. I'd say a 35 to 45% reduction in the fee and then, some of the PPOs have even frozen their fees or even in certain cases, dropped their fees. And you know, the Delta Dental lawsuit in California was just settled. The dentists won that in the short term in the sense that the court found that Delta did not give enough advanced notice. But tomorrow, could give 120 days notice I think it is and they could adjust the fees to wherever they want them to go. So, we are seeing some of the plans have actually dropped the fees. 

Howard : Well, what did ... your staff under on this, it's under newsletter resource, forms, consulting, is it under consulting, your team members? 

Dr. Blair : I think over there in the ... about ... in the list, we've got roughly about 10 employees. 

Howard : Yeah. Well, I was wondering ... you got your son, Trip works for you, Mason works for you, do you think ... if one of them ... if your granddaughter said I want to go to dental school, with all these shifting from indemnity to PPOs to corporate [consultative 00:08:55] group, do you think that you and I graduated in the golden years and they no longer exist or what is your macroeconomic view of where dentistry is today from when you came out of school at UNC? 

Dr. Blair : Well, I think in that era and later in yours, even during yours also, that the profit margins were more substantial than today, and I think the bottom line, as a group, dentists will make less money than in our generation. On the other hand, what's better to be in today, as we look at the different vocations and what's available to the young person today, I still think that dentistry is compelling. The problem though is that one is debt, the average debt, I don't know about you, I was 11,000 in debt in 1974. That's about 45,000 in today's dollars. 

And now, depending on who you're reading, the average student today is getting out in the 250, 270 number and then, those that go to private schools can be up in the 400,000 debt service. And so, that is certainly a piece of the puzzle. And then, as they come out and work, they're working in a PPO environment and making less money. I've been around practice sales for a long time, I've been out of practice sales here for probably 15 years or so, but keep up with it. My son-in-law, Joe Jordan is an attorney's and he's directly in debt today, and what we have today is pretty much a seller's marketplace. 

When I would lecture 20 years ago, I said if you couldn't pay for a practice in five years, it was probably overpriced. Today, we're seeing 10 and 15 year financing because of the lesser profit margins but it's still wide open. If a young doctor's got two years of experience and they've got good credit and they haven't run up their credits cards and so forth, even if they're several hundred thousand in debt, of school debt, still, it's wide open on purchasing of practice and of course, some are opting now to work for corporations. Some work for the corporations a few years and then, get their own practice. Leave. Others bounced back. Some come back for that corporate environment where they can basically come in and punch the clock, do their work and go home. 

And so, we've got the different options today, I think more option than when you and I went into practice. 

Howard : Yeah, when we came out of schools, if you want a job, it's just basically the army, navy, air force, marines or public health and in-house service, now, these new kids, they got tons of options to get a job. 

Dr. Blair : That's correct. 

Howard : I mean they can get jobs all day long. What did you want to talk about ... well, first of all, do you think the PPOs will turn into EPOs and this will just continue to deteriorate earnings for the next 10-20 years? 

Dr. Blair : I think that the way it looks, that the EPOs are coming in. It's not extremely dramatic but they are coming in, and I think that the new normal is going to be a lesser fee structure. It means that a lot of existing dentists are going to have to work a little harder to make the same income. It also means they've got to be very savvy, they've got to do same date dentistry, they need an operatory that they can work in procedures today that are not on the books and all kinds of things. They've just got to be much better business people. I think when we got out that you could almost, I know in my area down in the Carolinas, you could open up and in spite of yourself, do extremely, extremely well. And I think the margin today for the young doctor is much tighter. 

Howard : Yeah. So, what did you want to start talking about? You got five books, did you want to start with coding or what, what did you want to start with? 

Dr. Blair : Yeah. Let's talk about coding. I thought I'd give just a few tips and ... 

Howard : No, we want all your tips. We want every single last one of them. 

Dr. Blair : So I thought I'd just give some codes that maybe folks don't know so much about or have not heard of or whatever, and I would say that one of the number one codes that is underutilized is the palliative code, and that's code D, as in delta, D, 9110, 9-1-1-0. And the palliative code means emergency visit, minor procedure and the key on this, Howard, is that you've got to write a narrative and narratives electronically can't be more than 80 characters and be guaranteed to get through to the insurance company on the other end of the circuit, but you always could do an attachment with an unlimited amount of information.

The palliative code means amount of procedure at that emergency visit. Things such as adjusting the bite, maybe the tooth is sore, removing decay, putting RM in, smoothing the sharp edge of a tooth, painting something on an [inaudible 00:14:16]. So, I would invite our viewers to certainly look up code 9110. A second code at the emergency visit that we don't see utilized is code 0460. This is the pulp vitality test and the pulp vitality test means, of course, as you know it, could be percussion, hot and cold application, electric pulp test. At the emergency visit, if I'm just looking at the patient, writing a prescription, consider 0460. The typical practice is going to use 0140, the problem-focused exam, that burns up an exam. Take an exam away from the patient. And so, we would like to decrease, if you will, the count of code 0140s and try to use more appropriately 9110 when we can, code 0460 when we can. 

And so, that's at the emergency visit. Now, two codes that I see that just almost universally doctors don't know about, 2971. Two nine seven one is additional procedures to construct a new crown under an existing partial denture framework. So Miss Jones wears partial going in and out of the mouth, and now, we got to make a new crown. Well, we got to send that impression to the lab, we got to send the partial to the lab and the lab then do that for free. They're going to charge a surcharge of typically 50-$60 extra. And so, a lot of doctors will just jack up their crown fee, but the problem is if I'm on a PPO, it just increases my write off. So, there is a legitimate code for these additional procedures and by the way, the CAD/CAM doctor, the doctor with CEREC or PlanScan, it's 2971 and the fee on that is roughly 150-$200 put down your crown, separately, put down 2971. 

A second code that a lot of offices don't know about is sectioning a bridge. And this is where say a three-unit bridge is failing and we're going to keep a good crown retainer in the mouth, so, we section, we polish what stays in the mouth and then, we extract the crown retainer portion along with the pontic of that three-unit bridge. 9120 is for sectioning and polishing. Separately, we would code out 7140 for the extraction. So, that's a couple of codes that are not as well-known out there, and the 9120 is an addition to the extraction. 

Now, we find on, Howard, in the area of implants, there's a lot of confusion. And part of the implant-related codes are in perio, for instance, guided tissue regeneration, the membrane, there's a resorbable membrane 4226, a non-resorbable membrane 4267 and those are in the perio area and then, in the implant area starting with code 6010, we have the implants. And then, over in oral surgery, we've got the sinus lips, the bone grafting and some of that. So, it does get pretty confusing. I would say that the number one confusion in terms of submitting a implant crown is the two systems. The most common system, as you know, is the abutment supported crown, that means where the abutment is placed first, and it could be, say, the custom abutment, 6057 and then, we put the crown and cement it or bond it on top and so, that, say, it's 6058 ceramic crown. 

Notice that the doctor, the GP here is putting two different pieces in the mouth, the abutment and then, the separate crown. The other kind of system is the one piece UCLA crown and that is a one-piece screw retained crown, that's code 6065, and there, we're just putting the crown in. There is no comparable abutment. Now, the thing about the one-piece UCLA crown is that we see some of the laboratories that are billing out the doctor for the crown and for the separate abutment but yet, the laboratory is delivering a one-piece crown to the doctor. And so, the coding, the appropriate coding is 6065, and it's unfortunate because frankly, from an insurance perspective, we get a better reimbursement when we are separating the crown and the abutment separately. And so, 6065 would be the one-piece UCLA crown. 

Another area that we find that a lot of doctors are not aware of is that the codes for implant overdentures have been changed and the 6058, the 6059 overdenture is now gone and in its place is 6110 to 6113, and this is a removable overdenture. And a lot of offices don't realize that we got these new overdenture codes. There's also an associated locator. You know, a locator is made up of a male and a female piece and 6052 is a relatively new locator. So that's what we see, Howard, I think that's kind of hot in the implant area. We've also got some bone grafting, 7953 is the bone socket graft, so we pull a tooth and we put a bone graft in today, that's a 7953. If we put an implant in today and simultaneously, put in a bone graft, that's a 6104. I know I'm spouting out a lot of numbers here. What I would suggest is the listener just kind of jot down some of these codes and then, go into the resource materials to look them up and that type of thing.

Another area that is relatively new is we've now got a new code for ... it's 4346 and Howard, it's a code related to gingival inflammation and there's no scaling in the presence of moderate or high gingival inflammation and this is where the mouth is on fire. Here comes the brand new patient in the door. We can do an exam. They might have calculus [crude 00:21:35] but we can do an exam on the new patient, there's no bone loss. So zero bone loss here, so it's not a perio patient. And so, this is what I call kind of the dirty mouth code if you will. In the past, we'd have a mouth come in like this, and we would do two pro-fees on them and maybe wait a couple of weeks between the two pro-fees. Today, we bill out 4346 for the first visit and then, a pro-fee, say, a few weeks later. 

Now, what about the 4346? How is it handled? Well, it's handled about the same as a pro-fee, paid as a pro-fee subject to the typical two pro-fees per year limitation, that type of thing. In a few cases, 4346 pays a little better. In a few cases, unfortunately, there's a deductible and a co-pay, but fortunately, that's not very much. So, that is a new code, 4346. Looking at the new codes next year, they have cleaned up the full mouth debridement code, and I want to explain about the full mouth debridement, and the name of the code is full mouth debridement to enable a exam. And this is the code where the patient comes in, brand new patient, I can't see the teeth. There's so much calculus crude obscured, and I'm going to preliminary clean them up. 

I'm going to do a major film such as a full series or a pan, and that's all I'm going to do. I'm not going to code out an exam today because they're so obscured and once we get the calculus and crude out of the way, we need to be some healing. And so, 4355 is done in conjunction with a major film. And then, after, say, 10 days, the patient comes back. Now, we can see the teeth. We would charge out the exam at the second visit and that exam is code 0150 or code 0180. And then, at the second visit, we're going to either do a pro-fee to finish him up, or we're going to start our scaling and root planing. 

Now, I did want to give one other plural about the new exam codes. Everybody, all the listeners know about code 150, that's a comprehensive new patient code but what about code 180? That's a comprehensive periodontal exam, it can pay better, and it can be the proper code to use. That code is not just for periodontists but it's for GPs also. And so, the key here is when the patient comes in, for the new patient, are we treatment planning SRP or not or referral to the periodontist. If the patient's a perio patient, for the new patient exam, use code 180, not 150 and there, the doctor may enjoy a little better reimbursement, or the patient is paying a little bit less out of pocket. 

And so, we like code 180 for new patients because of that typically a little higher reimbursement. We can use 180 at the check up, it would have to be though a 4910 perio patient and also, at the check up, we would have to do a full blown probing and charting. And remember, all of the exam codes, the doctor has got to see the patient unless it's a special state where the [Hugginist 00:25:17] can independently practice something like that, then, it may be a different story. So that's how that works. I would also say that one other area, and I've got just a couple more and then, I'll just kind of pause for any dialogue. Scaling and root planing. There's some confusion about that. 

Insurance companies are basically looking for three things with scaling and root planing. They're looking for a 4 to 5 millimeter pocket depth, bleeding on probing, which indicates active periodontal disease and then, they're looking for, particularly bone loss. I can't get on the root of the tooth without some bone loss. And so, we're seeing some crackdowns here, some tightening, we're finding too that doing four SRPs at one time, four quadrants on one date, unless that's prior approved with a specific reason, that that's going to be what we call disallowed. By the way, as far as these PPOs go, there's a term denied and this is where, Howard, a lot of folks leave money on the table. Denied means that the company's not going to pay for it, but the patient can be charged. Disallow means the company's not going to pay for it and you cannot charge the patient. So, that's how the difference between denied and disallowed. 

And I guess the final thing I want to talk about is orthodontic records, we're seeing more and more doctors getting into invisalign and various aligners and so forth. If you are addressing both arches and it's an adult comprehensive case, then, the proper code would be 8090 for the case fee. But in ortho, we can also charge out records separately and records, ortho records per se invisalign would be photographs, code 0350 and would be steady models, the diagnostic cast, code 470. By the way, the diagnostic cast can be virtual, so I can take with the new digital impression technologies. I can take some virtual diagnostic cast, if you will, and as long as they could print upon request, then, we can legitimately charge out a code 470. 

There's three reasons that we want to submit the records separately from the, say, invisalign case, one is cashflow, let's get paid, number two, it's early warning, if they won't pay for the records, I know they're not going to pay for the case and then, finally, some plans will pay ... the typical ortho lifetime benefit is 1,500. So some plans will pay 1,500 plus the records fees and others, the records come out. So, you can see in this kind of summary here that this coding is pretty technical. Once you get up on the curve though, Howard, it's a matter of just updating, and one thing I want to really emphasize for the younger doctors here is that their name goes on the claim form. And if they're working for a corporation, and the coding is improper, the state board goes for the doctor, not for the corporation, the doctor has the license. 

And we've seen several young dentists here in North Carolina that had some issues of scaling and root planing over treatment, and so, the doctor's name goes on the claim, and the doctor is responsible for that. 

Howard : Every six months or so, you see on the news someone getting in trouble for fraudulent billing and it seems to be always with more government like Medicaid, not private insurance, I'd say Delta or something like that. And a lot of the dentists always claim that they were just ignorant and doing it wrong and then, was thrown into the [tire 00:29:31]. What do you think about what I just said? Do you see these new stories of people getting in trouble with Medicaid and billing and getting in big time trouble and do you think it really is ignorance or do you think it is fraud? 

Dr. Blair : Well, just looking at a number of those situations and the ones that really take the news, there is a presumption of innocence, but on the other hand, a lot of these Medicaid situations are fraudulent and fraudulent in the sense of I turned in 500 stainless steel crowns but only did 200 stainless steel crowns and a lot of times, it's with kids because the major Medicaid benefits are for the children. Something for you to be aware of and also, the listeners is there's now what's called RAC audit, recovery type audit and it's where a third party comes in and audits the practice, and I think they get around 12% recoupment. Every dollar they can find, they get 12 cents on the dollar, so they're kind of a bounty hunter. 

And I think that people that really have exposure, it's like if you own four or five different Medicaid offices and if there's some allegation of wrongdoing, then, depending on the state and their protocols, they might suspend payment. And you could imagine the cashflow, if you're getting almost 100% Medicaid checks, it's a disaster if that would be held back. So, the ones that you see that tend to make news are the Medicaid because a lot of times, it's huge amounts of money. A lot of times, there's maybe multi doctors in that clinic and so forth. But we see the other traditional companies, the Deltas and so forth, others, certainly taking action on fraudulent action. I agree that they don't make quite the headlines that probably the Medicaid has. 

Howard : Before you go on to your next subject, I want to talk about you ... I've seen you lecture several times, as far as PPO strategy or fee positioning or strategic planning, I mean some are going to say, "You know, I'm so sick on all these insurance, I'm so sick all these PPOs, I'm just going to drop it all." Do you think some people can do that? Because some people say that 40% of Americans have no dental insurance. So, there's 325 million Americans, if you don't want to have lower prices, higher overhead, more volume practice, I'm just going to drop all the insurance and focus on the 40% of Americans that don't have insurance. Obviously, that's a strategy but do you see that strategy being executed very often or very successfully in your professional view? 

Dr. Blair : We don't see that very much. What I do see is a doctor that, say, Howard, gets into IV sedation, they got some special training, those special deals, so to speak, a patient that is fearful and so forth will come to them out of network and they're primarily in the bigger cities, I've seen them do extremely well. I think for a doctor though just to say I'm going to drop everything I've got and just go bare, so to speak, without a real, real plan, I think in this day and time, it would be exceptional if they could pull that off in a positive way. So, there's certainly doctors out here that are concentrating in ... they're kind of a decathlon doctor, they do all kinds of procedures. Like I say, they do the IV sedation and so forth, and they may not be in any plans at all and do extremely, extremely well. 

The other problem is that insurance is undergirds the average patient coming in far that has dental insurance and getting treatment and so forth, and to give up that component would be awfully tough. So, I think a lot of people just might say I'm going to drop everything but they really need to have a plan. If they're going to do it, I would also urge them to phase out. Now, one thing about it, though, is that to just join 30 plans and be in everything in the world I think is just crazy. I would look at being in four-five plans and then, an in-house discount plan, for people that don't have insurance would be another option, it's not dental insurance. 

But this day and time, and you know, there's probably nobody that thought this more than myself over the many, many years and I used to have a little checklist, I'd tell doctor, do all these other things before you even join a plan, and a lot of them can get the checklist done. But today, the marketplace is so different today and with the number of PPOs out here, we are at the point now that roughly 90-95% of dentists are at least in one PPO at this point? 

Howard : What percent? 

Dr. Blair : About 90-95%. Or at least in one PPO. Now, the one PPO out there is Delta Dental for the most part. 

Howard : Okay, so, Delta is certainly a PPO? 

Dr. Blair : Yeah, they are the gorilla, and Delta is definitely a PPO. Now, Delta has two levels, there's Delta Premier, which is I'll call it a high-end PPO and then, you got Delta PPO that's more comparable with the fee structure to the other PPOs. Delta Premier though, the problem with this Delta Premier is employers today just don't want to pay the higher premium. And so, Delta has got serious problems throughout the country of employers opting for the cheaper PPO plan and yet, Delta has a lot of these grandfathered premier doctors, and a grandfathered doctor gets the premier fee from a PPO patient coming in. 

Howard : So, what do you think Delta will do? 

Dr. Blair : Well, they're doing several things around the country. There's four or five states that ... For instance, California. If you sell your practice to somebody or you bring in an associate or whatever, then, they're at the PPO fees. They can't come in and be grandfathered as a premier. And then, I understand, in California also, that if you move your practice geographically, that you've got to be a ... again, you lose that grandfathered status, or if a doctor opens a second location geographically somewhere else. And then, there's four or five other states that have similar situations. 

Howard : So, Delta Premier's their high-end, what's their lower end called? 

Dr. Blair : It's just called Delta PPO. Howard, there was traditionally about a 20% difference between the two, and that is decreasing. What some states have done, for instance, Tennessee, I understand has frozen the Premier for the last six-seven years or so and then, the PPOs has been increased a few percent per year. And let me say this about Delta too, and I'm not a big insurance basher or whatever, they, business-wise have been put in this position of where the market has changed and the employers just don't want to buy the more expensive premier level policy, and that's what's going on. 

Howard : Dentists are just whiners. I mean when Americans go buy their iPhone, do they have some insurance that ... some [cells 00:38:08] got the boss to pay for iPhone insurance or smart phone insurance? I mean the fact that these guys go out and sell, I mean ... How much insurance do you think they sold last year or for 2016 or ...? 

Dr. Blair : How much insurance. You mean ... 

Howard : Yeah. I mean what did Delta do? In 2016, wasn't Delta like 19 billion or something, they're like 1 billion just in California alone? 

Dr. Blair : Again, I don't know the exact number on that but I wouldn't be surprised. Our profession at this point, I think is, what, 115 billion or so, it's roughly the dental profession. 

Howard : Right. 

Dr. Blair : And that would be the total billings if you will. And insurance, a lot of offices in the cities, particularly, there's 60-70%, if not higher dental insurance. 

Howard : Dental insurance, you mean 60-70% ... 

Dr. Blair : Dental insurance. Now, they may or maybe out of network on some percentage of that, but in other words ... 

Howard : Six ... so ... 

Dr. Blair : Sixty percent ... 70% of the people walking in the door have got a insurance policy. Now, the doctor-

Howard : Okay. So you're saying 60 to 70% of the patients ... 

Dr. Blair : Patients. 

Howard : ... came in with insurance? 

Dr. Blair : Came in with insurance. 

Howard : Not strictly the 70% of revenue? 

Dr. Blair : That's right. 

Howard : Right. 

Dr. Blair : And so-

Howard : Right. And the data is clear on that, is that when people have dental insurance, they're far more likely to go to the dentist. 

Dr. Blair : They are and that's [inaudible 00:39:37] ... 

Howard : And if the dentist don't like it, you know, they give the American Dental Association a thousand dollars a year dues, they don't sell any insurance. And then, here's Delta and all these companies selling billions and billions of dollars, getting employers to pay for billions and billions of dollars as subsidies to their patients and all the dentists is ... is whine about it and bash it, when it's the marketplace and if it's so damn easy to go sell all these expensive dental insurance, why don't you sell your dental office and go start a dental insurance company. 

Dr. Blair : Yes. 

Howard : I mean obviously, it's easy. I mean obviously, you just walk in at any company. What was the one that ADA was trying back in the day? It was hilarious. What was their plan? Where there'd be no middle man, no insurance ... 

Dr. Blair : Direct reimbursement. 

Howard : Direct reimbursement. 

Dr. Blair : That was the fantasy ... 

Howard : Oh my God. 

Dr. Blair : That was a fantasy about 45 years ago. 

Howard : And explain to the kids what these idiots really thought would happen. Explain direct reimbursement. 

Dr. Blair : Well, this was, again, 40-50 years back, time passes, but the profession felt like with dental insurance coming in, the profession could have a competing product that kind of cuts out the middle man. And so, the concept of direct reimbursement is that the employer sets up a plan, and let's say the first $500 is reimbursed to the employee dollar for dollar, the next thousand is reimbursed today at 50 cents on the dollar. And so, the employer sell funds, sets up a plan of direct reimbursement, and what's good for the employee and for the dentist is that anything is covered. So, it could be teeth whitening, it don't matter, any kind of valid dental procedure. 

Now, the problem was there was no brokers to sell it, there was no networks, if you will. Also, it did not hold cost down in any way and so forth, and so, the bottom line is it's just kind of gone. By the way, I believe it's around three-tenths of 1% of the marketplace at this point. So, it's a non-factor. So it's-

Howard : And how many millions of dollars did the ADA spend and how many years trying to get this off the ground? 

Dr. Blair : Well, many, many years. I know here in North Carolina, we had an employer too for many years and I believe, at this point, we don't have that overhead anymore. So, it's been a losing battle. 

Howard : It's the same problem. People talk about dental insurance they do politicians, people always say, "Well, they should have done this," it's like, "Hey, your politician had a choice between A and B, and what you're talking about wasn't one of those choices. So, why are you ..." You know what I mean? I mean they always ...

Dr. Blair : That's right. 

Howard : They think every one of their congressmen should have wrote a unique book and a unique law and it's like ... that ain't how it worked. He basically had a yes or no on this Bill. And it was 20 gazillion pages long. What percent of offices take nothing you say? 

Dr. Blair : Oh, I'd say-

Howard : No insurance. 

Dr. Blair : Well, now, they don't participate with PPOs. They take insurance but they're out of network. So, they are full fee per service practice. I think that's a 5 to 7% of the marketplace at this point. 

Howard : Is it more likely to be rural where you're the only guy in town or ...? 

Dr. Blair : Could be. Yes, sir. I think that it's more rural-based. It's also certain states like South Carolina is, traditionally, hasn't had much participation, although, that is changed a lot here the last 12-18 months. It's also frankly the older doctors, the doctors that have set up and established a name reputation and some, frankly, are still kind of milking their recall system and living off of the recall system. We look at three things as far as practice viability. We look at collections for the last three years. We look at new patient flow for the last three years. New patients would be code 150, code 180 and the third thing we look at, Howard, is how busy is the doctor. Is the doctor solid week and a half, two weeks absolutely solid. Then, hey, don't join anything anymore, you're in pretty doggone good shape. 

If you're below one week solid though, if you're less than four-five working days solidly booked out, then, there's not adequate doctor busyness. Now, on the other end of the spectrum, we see this sometimes, the doctor, this in 30 different plans and booked out six weeks. They need psychological help, they need a psychological counselor to be in 30 plans, and then, the doctors booked, say, six-eight weeks out, you can't get to the doctor. So they need to trim those plans back obviously. So, we look for the healthiness of the practice, the where are you, what's your new patient flow been the last three years, what's your collections, and how busy is the doctor. 

Howard : So, what is the average number of plans? So five to seven percent are not in any network, so then, the rest, 95 [inaudible 00:45:19] ... 

Dr. Blair : They're at least in one plan, that's right. 

Howard : Yeah. In one plan, that's a PPO? 

Dr. Blair : And that's typically ... Delta is kind of the [inaudible 00:45:26], Delta was kind of the first in the marketplace. 

Howard : So, if you took out Delta ... 

Dr. Blair : The dentists actually started Delta in many states. 

Howard : So, if you took out Delta, what percent of the dentists are on additional PPOs? 

Dr. Blair : You know, I don't have hard facts on that particular one but I would think that ... I would say at least, I think at least 60% would be more than two PPOs at least. 

Howard : Okay. So, how does this doctor who's taking ... Okay, the problem is very simple in dentistry. So, you go to the grocery store and buy a bottled water. The grocery store knows I bought this for 80 cents, I sold it for a buck. You go into the dental office and the dentist gets to undo an MOD composite, you say, "Well, what did that cost you to do that?" Take in all your overheard and divide it by the time you're in there, how much that cost. He has no idea. And then, he signed up for 15 different plans. So he doesn't know what it cost to make the filling, the crown. 

I mean I've never met a dentist in my life who got ... a hygiene check and I stop him, I said, "Hey, you've been checking Mary's hygiene for 12 years. She just did a clean exam and bitewing." What did that cost you, what did you make. Did you make money. So they have no idea what their cost are, and they're signed up for 15 different prices on a PPO. What resources would you recommend to that doctor to have someone come in and valuate if you're on 15 plans? What resources would you recommend? 

Dr. Blair : Well, we don't do this but there are companies out there that do the PPO negotiations and so forth, and either the doctor and their team or a professional negotiator should be negotiating with that PPO either on an annual basis or every two years, absolutely. And a lot of doctors-

Howard : Do you think these are successful? 

Dr. Blair : Well, again, it depends-

Howard : I mean are you hearing good feedback on these PPO negotiators? 

Dr. Blair : In general, I would say yes. The thing that the negotiators know is that there's out here called leased networks and things that are seeking people in their networks and let's say that a traditional PPO just won't negotiate with the practice, but yet, that PPO might be a member of a leased network and this leased network over here that has multiple PPOs in it will give you a better fee schedule. So, there is some sophistication there. Also, some of the PPOs will not negotiate with a third party. Also, Delta Dental historically has not really negotiated. It's more of a take it or leave it. And so, it depends on your ... I'll call it your portfolio. If the only thing that you're in is just Delta and maybe a PPO that won't negotiate with a third party, then a third party negotiator is definitely not for you. 

When we look at these PPOs, we look at fees, what's the fee structure. Number two, what's the quality of the patient, is this based of this group. And then, number three, what's the administrative hassles, and so, what hassles do they offer. And that's how we kind of look at a PPO of whether to drop it or not. And another thing I want to emphasize, Howard, is that, you always put your full fee on all claims, you never ever put a PPO fee on any claim form. And so, for our listeners, that is very, very important, to put the full fee down so I can ... We do that for four reasons. One, I want to measure write-offs. Number two, I want to, with the write-offs, it is good or better, number two. I want a full fee so I can capture any PPO increase. Number three, if it's dual insurance, then, the secondary carrier needs to know what the full fee of the practice is. 

So those are some reasons there. And then, another is to put the full fee down to influence the PPO with your overall fee schedule. So, we see some errors. What offices don't know when there's dual insurance and there's PPOs involved, the PPO with dual insurance is going to control what the patient pays but they do not control how much the practice can make. So, in the best of circumstances, the practice might make its full fee. Another thing we see is offices that say, "Oh, we don't process secondary claims. We'll just do the primary claim. Patient, you make your deductible payment to us and we'll give you the secondary claim and then, that money comes to you." No, no, no, the doctor should control the primary and should control the secondary and coordination of benefits means it's good, we're getting two checks. Non-duplication of benefits is bad. That means the secondary payer, if it's non-duplication of benefits, what that means is is it secondary didn't pay anything, if primary pays, what secondary would pay. 

So let's say I'm secondary, I'm ready to pay $500 but primary pays 500, I pay nothing. And so, we find that so many offices and every time I give a seminar, I give a quiz, my expectations are low and the group universally flunks the aspect that you can collect up to your full fee and that's one thing and then, the patient always gets the benefit of the lower contracted fee. So, if there's two PPOs, let's say that the full fee is a thousand, one PPO is at 800, one PPO is at 7, then, patient responsibility, assuming the office is contracted with both, then, the patient responsibility would be 700, the lower contracted fee. 

And Howard, I want to emphasize to the listeners that I think most offices are probably at the 95% level of knowledge on coding, they always can learn more, they should have our resources, but in the administrative area, there's so much they don't know about and I'll be mentioning here in the next few minutes a number of areas that they just don't know about. And I would highly recommend our administrative book that we have that covers everything that we're going to talk about here. 

Howard : You were talking about Coding With Confidence, then, you have several other books, you have Administration With Confidence, Diagnostic Coding for Dental Claim Submission, Medical Dental Cross Coding with Confidence, Insurance Solutions Newsletter, what did you want to talk about next? 

Dr. Blair : I'm going to talk about the administrative book and what's in there. I want to talk about insurance administration and try to give the listener just several areas that probably are not on their radar and-

Howard : So, you're saying they didn't learn this in dental school? 

Dr. Blair : Absolute-

Howard : Is that what you're trying to say? 

Dr. Blair : Absolutely not. Along with all the other ... 

Howard : Isn't it bizarre?

Dr. Blair : ... business thing. 

Howard : Isn't it bizarre that you graduated in dental school and you don't know one insurance code? I mean isn't that just kind of bizarre? 

Dr. Blair : It really is bizarre when you think about it. And then, what's even more bizarre is that they need to be prepared when they go to their first job. It's not going to be their own practice, and it's going to be an associateship or working for a corporation, and they need to know this knowledge because like I said, their name, their provider, NPI number we call it, the national practitioner identification number, that goes on every claim with their name behind it. And then, they're often are getting paid a percentage of collections, and the money left on the table is their money also. So, it's very important for them to know what's in the admin book. Frankly, they ought to read it cover to cover. 

So, I'll go over some things at this point that a lot of folks just really don't know about. First of all, when you join a PPO, you sign a contract. That contract is four to eight pages long but the contract ... here's what people don't know, is that people or the contract makes reference to what's called the processing policy manual. The processing policy manual is typically 150-200 pages, and that contract says that the provider, the doctor shall adhere to what the processing policy manual says. Now, in that manual, and by the way, every PPO has a manual, every state Medicaid plan has a manual and Delta Dental has two manuals. There's Delta Dental of your state. So, let's say North Carolina dentists. There's North Carolina Delta Dental and that's for any policy sold by them in the state. But there's also Delta USA, and the Delta USA is a national contract. What would that be? For instance, Coca Cola in Atlanta, Walmart in Arkansas, Google in California. The Delta USA manual is a little different. 

So, they can go to the password protected website and they need to download the latest processing policy manual for their Delta Dental of their state along with Delta USA. The other PPOs have just one processing policy manual. Now, I want to discuss what goes in that processing policy manual and some of the things that that manual says. First, you got to report all services. So, if I do 10 crowns, even though insurance only pays for the first couple of crowns, I've got to turn them all in. If I do tooth whitening, I've got to turn in the tooth whitening even though they're not going to pay for it. If I do veneers, I've got to turn in veneers. So, all services for which you charge a fee are supposed to go in. 

Now, once you send that in, they may come back and say, "We're not going to pay for tooth whitening, Dr. Blair, but we don't like your $500 Zoom fee here. You've got to do it for 300." What did they do to me? They fee-capped me for non-covered procedures. In other words, insurance is not paying for it but they're controlling my fee. Can they do that? Yes. The doctor might say, "Well, our state has passed a law against that," roughly, 40 states have passed laws against this fee-capping. But guess what, and this is so important. There's two kind of patients that walk in your door, there's the insured plan patient and that's a patient that's an individual that buys a policy. That's a small business, Joe's Machine Shop buys a policy, that's under the insurance commissioner of your state. That's under state law, that's under prompt payment laws, that's under the fee-capping law. 

But the problem is, Howard, is that the insured plan patient is about 25% of people. Seventy-five percent, 75% of people walking in the door are self-funded plan, and a self-funded plan is under ERISA, is under federal law, and your state law for fee-capping is worthless. So, these doctors that think that our state's passed a law, it's going to protect me, it protects that doctor with, say, 25% of the patients with insurance but not the other 75. Now, a self-funded plan is under ERISA. How does that work? Let's say it's Bank of America. Let's say that Bank of America hires MetLife. Well, MetLife provides an actuary to design the plan for Bank of America to keep it within Bank of America's budget. MetLife provides a low-cost doctor network, and then, MetLife pushes the paperwork. 

So, MetLife handles all of the claim submissions. Well, MetLife is paid a fee per claim. A typical fee in the marketplace, I understand, is about $7 per claim. So MetLife is making 7 bucks per claim. MetLife is not at any financial risk whatsoever, it's Bank of America. And so, the self-funded plan can fee-cap you. And how do we know it's self-funded? Well, it could be a union, it could school teachers, it could a hospital, it could be a major corporation, it could be American Airlines. If the patient has an identification card, on the back of the card, it says, "Administered by Guardian" or it says, "Administrative Services Only" so, if there is a patient card on the booklet ... and by the way, when the patient brings in their booklet, the technical name of that is summary plan description. And the summary plan description on the back page, it may say administrative services only, MetLife as an example. 

Now, by the way, this little booklet the patient brings is not the keys to the kingdom, the plan document is. And this is not, again, on the typical radar of any office. The plan document is what the insurance company uses to administer the plan. It's 150-200 pages long, and this plan document, the doctor can't get it but the patient can. Under Department of Labor federal law, the patient goes to human resources and they must be given a copy, Howard, of the plan document. Then, the patient brings the plan document back. That's the keys to the kingdom. In there, it might say that if there's osteo surgery, we'll pay for an occlusal adjustment and an occlusal guard. It might say in there that if the patient's diabetic or pregnant, we'll pay for an extra pro-free. So you just don't know what's in the plan document and I would recommend that each practice would collect the top 10, 15 employers in the area. Not insurance companies but the biggest employers that you deal with get their plan document. 

Now, I want to go back to the business of the processing policy manual. This manual, again, says that you've got to report all services. The manual spells out how to handle optional services, that's where the patient wants a composite instead of an amalgam or they want some type of maybe a full mouth rehab or whatever. The manual also spells out that you've got to bill the PPO whatever, either their fee or the practice fee whichever is less. So, what about that practice that runs a $99 special for August? What goes on the claim? Whether you're in network or out of network, if your fee is $99, then, 99 bucks goes to the insurance companies. 

What's illegal would be to tell Miss Jones, "Miss Jones, you got a coupon here for $99 special. We're going to honor that. But I'm going to bill your insurance company at our full fees and then, whatever they pay above 99 bucks, I'll just give you that as a credit. I'll fee split with you and give you a credit on your ledger card." Well, that just gave you two ways to go to jail.

Howard : Yeah. 

Dr. Blair : So, those kinds of things, we cannot do. Another thing I want to emphasize is the coding is the same whether you're in network or out. So, the coding is exactly the same, I report what I do always and then, it's the write offs and so forth. So, those are the things that come into play. I can't emphasize enough that they get the processing policy manual for every PPO that they're a member of it and they particularly look at how to handle optional services. That generally is addressed in the processing policy manual. 

Howard : Charles, what percent of dentists know basically nothing about coding and have never even submitted an insurance claim and couldn't even get on their own computer and enter a filling and a crown and a root canal and submit it to the insurance company? 

Dr. Blair : Probably half or so. I would think that ... or just purely dependent on their team and say, "Well, let Mathilda handle this." And I think that's the biggest error in the world you can make. I think part of the doctor's responsibility is to understand coding, understand insurance administration, and after all, you just don't want to leave money on the table. And of course, you don't want to get into any problem either but doctors to me are very trusting, very naïve in many cases, and there's not much emphasis, of course, in dental school on this, all the emphasis is on clinical of course. And as you know, the business side in the dental school is a secondary thing and I think part of that is got to be the way that the school works. 

But on the other hand, I would tell the schools that they really need the student to be involved in the coding, in the insurance administration, and all of that is just very, very important. 

Howard : So you think you'd ever write a series of articles for Dentaltown Magazine on these books that you sell? 

Dr. Blair : I could do some articles on some of these, yes, sir. 

Howard : I would absolutely love that. I mean, but it's not just dental schools like you meet these kids who just graduated from high school, right, here on Phoenix and they don't even know how to balance their check register. They couldn't go to Chase and balance their checking account but they were teaching them algebra, geometry and world religions. It's like why did they have four English courses when Google and your smartphone will spell check everything for you? Obviously, spelling's gone out the window anyway, everything's emoticons and whatnot, but yeah, my job is to try to take that little puppy and stick their nose into what they need to pay attention to and they always want to stick their nose in the clinical, which is cool, I get that. But gosh, darn, you just said half the dentists don't know how to do this. 

So if some dentists is listening to this thing and says, "I'm really not interested in any of these stuff, but how could I get my office manager and my staff educated, ramped up on all these the fastest?" What would you tell them?

Dr. Blair : Well, the issue is will they read the books, our online system there, the Practice Booster is 2.97 a year, and it's got all the codes in it, electronically. It's got insurance solutions, newsletter, archives, it includes insurance solutions or the newsletter. Now, I do some private. I handle about 200 private clients a year. I have what I call the revenue enhancement program. I get on with the doctor and their team for a roughly two and a half hours, two hours coding, 30 minutes administration. Also, rebalance their fees, give them some feedback, give them your support. So there is some support out there, but again, I can handle personally about a couple of hundred clients a year with my other obligations that I have, Howard. But, gosh, if we could just get people to read. 

The other thing that would stun you ... not stun you but when you go to a CPA to have your taxes done this year, what's the odds that they have up-to-date software, that they know the latest tax law, that they're calculating your taxes correctly? It's about a 99.99% of the CPA's compliance. What would be the number of dentists that have an up-to-date code manual today, either the ADA or my code manual, or whatever? It's about 30%. So about 70% of doctors don't see the value of even buying a code manual, this current. And even though the ADA code manual is only $49, mine's 109, but mine has added value. It has the narratives and all the other things. 

So, I would say that this day and time and this is one reason why I think we're so vulnerable to the corporate dentistry, is that those dentists that opt to be independent, they've just got to be efficient when it comes to OSHA and HIPAA and coding and insurance administration all up and down the list, you've got to be efficient at that, or you're dead meat today, and your profit margins are less. You've got to be a great marketer, all these other ... And that's all above and beyond if you know the clinical side. 

Howard : You know, not only leaving money on the table by not even knowing these codes and [believing 01:08:50] on these codes but any consultant will tell you that, when they go in the office first day, they just observe, see what's going on. And at the end of that day, if you just do a survey of everything you did in the back and everything that was entered, there's always at least 250 to $300 per day in every dental office like the hygienistic bitewings but didn't enter the bitewings or the assistant ... 

Dr. Blair : That's right. 

Howard : ... took a PA or a bitewing to see if the crown was [seated 01:09:16] but didn't bill it. I mean they leave 3 ... How much money do you think they leave on the table? How much money do you think the average dentist leaves on the table every day because either it wasn't even entered in the computer to begin with or they missed so many opportunities on insurance billing? 

Dr. Blair : Well, I think it's certainly several hundred dollars a day. That's one reason why I highly recommend that the doctor take about 30 seconds in the morning and they need to learn how to do it. Just hit the button in the computer and get a productivity report for yourself for that morning and then, at the end of the day. This way, it just takes you 30 seconds to look I did two crowns this morning, is that in the computer, I did a core build up, is that in the computer this morning. And do that for the morning, do that for the afternoon, and of course, what's my goal today, that type of thing. Some people monitor ... I advise at least a 15% same day dentistry revenue. So, in other words, if your goal is 5,000 for the day, 15% of that should be same day dentistry. In other words, it was not on the books today and we work that in today with our on-book operatory, that type of thing. 

I've got a couple of more comments I wanted to make here before we get to the end of our session. I wanted to mention that discounts are typically okay. For instance, the preacher comes in, I want to give my preacher, on an individual basis, 50% off today, it's a thousand bucks, we charge him 500. Grandma comes in, [inaudible 01:10:59] comes in. So again, just kind of isolated discounting is generally okay. Let's say the preacher, I charged $500, he writes his check and then, he says, "Wait a minute. My wife tells me I've got insurance now under her new employer and so forth. Can you file my claim?" "Sure, preacher." What goes on the claim form, the thousand or the 500? Well, it's going to be 500 because that was my specific today for the preacher. 

Let's say the preacher comes in the next visit and I say, "Hey, preacher, you got great insurance now. You know, it's so good. I'm not going to require you to pay a co-pay or deductible, preacher," he says, "Oh, great". Now, what's wrong with that? Turns out every state has lost against co-pay forgiveness. Your every PPO contract says you can't do co-pay forgiveness, ADA code of ethics. If you remember the ADA and abiding by the ethics, you're not to supposed to do co-pay forgiveness. The federal plan say you can't do it either, but ... and again, we're not lawyers here, everybody might do a little bit of it. And if you did a little bit of it four-five times a year, again, I'm not advocating that but if you did, be sure that on the claim form that you put that the patient is not participating in the cost of care, at least alert the PPO or regular insurance. It don't matter if it's PPO or I'm out of network. I might have put on there that the patient's not participating in the cost of care. And so, just be sure that you do that. 

So, that co-pay forgiveness is another animal there that really needs a lot of caution. Some other things. Patient gifting for referrals, staff gifting for referrals, some states, it's wide open, other states, it's illegal. For instance, in New York and North Carolina, we can't give a patient gift such as a [inaudible 01:13:07] drawing. If you refer somebody, I'll give you free tooth whitening. If you refer somebody, I'll give you a gift card, if you refer somebody. And even the staff, we can't give in North Carolina, the staff a monetary gift for referrals. Now, I could give the staff at the end of the year a bonus just for your support of the practice and I might take in consideration how much they've supported the practice, but as far as a direct gift, that's illegal under North Carolina law. 

Also, unclaimed property offices in every state. If I come in to your practice, Howard, and I overpay my bill a hundred bucks, you've got a hundred bucks of my money there in Arizona, I come back to North Carolina. I disappear, you can't find me. Can you keep that $100? Yes. You can hold it for what's called a holding period of time. That's usually between one and three years depending on your state and then, you got to turn that $100 over to the unclaimed property office. Now, I want to caution also those listeners right now is that it's amazing but almost every lecture I give out of the audience is a doctor who goes to the unclaimed property office and finds that they have money, their practice has money that is unclaimed there. Some insurance company or whatever maybe sent a check, it bounced or maybe the office never cashed the check along the way some way and there's money for the practice at the unclaimed property office. 

And while you're doing it, Howard, check and see that aunt Mathilda that died or whatever, the executor of the estate might not have known that she has her money in the bank somewhere, some obscure account. So you never know. So I did want to talk about the unclaimed property office. Our admin book also has in it, of course, everything we've discussed here, plus, information about negotiating with PPOs, plus information about the in-house discount plan where you set up, it's not dental insurance but it's a in-house discount plan for people with no insurance. It can't be marketed as insurance and so, the patient can join our savings plan if you will, and that usually is a fixed amount of money such as $300 or so, 350, for the first year of preventive services and then, establish a fee schedule roughly 15% off but have a specific fee schedule put in the computer for your in-house discount patients. 

So those are just but a few things on the radar of the listener here today, some of these coding and some of these from a insurance administration standpoint. 

Howard : Man, you know so much. It's amazing. It is truly amazing. They got to get [inaudible 01:16:11] to this and quit leaving money on the table. So, that was a really [inaudible 01:16:16] deal, so print out what's scheduled for the day, it takes you a couple of seconds and then, at the end of the day, print it out again to make sure everything was entered. 

Dr. Blair : Yeah, that's all it is. And the other thing it does is you may have a goal of 5,000 a day or whatever the goal that you have, you do your print out and you need to gross it up, in other words, if I knew what my write offs ... when I do one of these print outs, it's obviously going to be production, it's not going to be collections. And so, let's say my productivity, say it's a million dollar practice, you might write off 15%. Now, some of your PPOs are 30 and 40% write offs but you've got cashed people, there's no write offs. You've got out of network, there's no write off on that. And so, hopefully, your write offs are not more than 15% total. 

So, you have a million dollar practice, you written off, say, 150,000, 15%. So, what I might do is just have a daily production goal knowing that overall, I'm going to collect, I'm going to have write offs of roughly overall 15%, 15-20% overall write offs. But a plural is to do that on a daily basis. The other thing I'd recommend is also do one on your hygienist. Let your hygienist do their own report, their own review but I like the doctor to look at the hygiene report. So I could look at Jane, what did she do today, what did Tammy do. Also, I've got some goals that they're going to do at least some scaling and root planing. They're going to do some 4910 perio treatment. And so, I can look at the activity of my hygienist. 

And again, once you read these reports, it's a 30-second timeline. It's just ... no time at all. Takes longer to print it out than to review it. But by doing that, the doctor has got their pulse, their finger on the practice. 

Howard : And just for the young kids who don't understand insurance, explain why all the states and the feds and everybody will not let you have co-payment forgiveness. I mean insurance is basically two things. It's an actuarial risk analysis verus moral hazard lying and cheating and when they based their premiums, they know the consumer making a co-payment really decreases demand. And when you take away co-payments, you have increased demand, that's why it's illegal, correct? 

Dr. Blair : That's correct. It's a misrepresentation. You're representing to the patient or rather, to the insurance company that there is going to be a co-pay and you're right, it's a form of controlling cost. It's getting the patient to put a little skin in the game, shall we say? And so, it's very important not to do this. And if it's done on a routine basis, we've seen people actually go to jail over a routine co-pay forgiveness type thing. So, it's pretty serious. 

Howard : How long did they go to jail for? 

Dr. Blair : I don't know but ...

Howard : Well, I know, I mean some dentists are crazy like they don't understand that something like 96% of all the crowns sent to the lab are a single unit. So then, some Einstein ... 

Dr. Blair : That's right. 

Howard : ... decide, "Well, I'll you what, Charles, you need a crown on 30 but I'm going to build a crown on 30 and 31. The insurance pay two halves and you don't have to pay me anything." 

Dr. Blair : That's right. 

Howard : And then, the insurance has these algorithms that they buy and they go through it, they find red flags, they'll say, "Okay. The average dentist bills 96% of their crowns one at a time and here's Frank over here and he's done a third of them two at a time." So then, come in in the office and the claims that you sent within your state are civil and fines and penalties, but the claims that you mailed and crossed the state line are now federal racketeering. 

That's why Al Capone went to jail. They didn't get him on murder and booze and drugs and gambling, they got him on mail fraud ... 

Dr. Blair : Yeah. [inaudible 01:20:49] I think ... 

Howard : ... and I know dentists-

Dr. Blair : ... too, didn't they ... for filing faults claims or tax returns or something across the lines or whatever it was, so ... 

Howard : You start doing mail frauds, it's five years per claim. I know a guy who went to jail for five years. He just had the perfect practice and a beautiful wife and two kids and the next thing you know, he lost everything. Went to prison for five years for billing two crowns to get two halves for one. And so, a problem with the young kids is they're young and they have these older dominant personalities trying to talk to them into doing something. What's the good word ... I always say, "Well, you don't want me to risk my life and go to jail, do you?" Who would say, "Oh yeah, I do. I do." 

Remember Nancy Reagan when she was all big in the say no to drugs that she really believe that a lot of these kids that are offered drugs, they don't know what to say so they just do it. What wording would you give to these young kids that are just coming out of school where older people are going to ask them to do things that are illegal? 

Dr. Blair : Well, I think it's very important that they do the straight and narrow. I think another thing is that what they don't understand, and you've been around a long time, I hear bad embezzlement every week. And so, when the team sees the doctor deviating with things, there's an incentive there for thinking that, "Hey, I can get away with the embezzlement here. If I get caught, then, the doctor can't do anything to me." So, I think I would just advise the young doctors that keep it very, very straight and be sure that-

Howard : Yeah. Blackmailers are very common with embezzlers. They don't talk about that because they don't ... 

Dr. Blair : That's right. 

Howard : ... say it, but a lot of time, they're sleeping with the dentists ... 

Dr. Blair : That's right. 

Howard : ... or they can tell the IRS he doesn't report his cash. 

Dr. Blair : That's right. 

Howard : Or he doesn't [inaudible 01:22:44] his company. 

Dr. Blair : He's seeing [patients 01:22:44] on a weekend. Yeah. 

Howard : Yeah. 

Dr. Blair : He's doing emergencies on the weekend, and the staff comes in and sees the gauze, the body gauze and one thing and another and then, what he should do is go up to the front desk and say, "Here's the deposit for this Saturday and here's $150 I got from the patient, blah, blah, blah," and make kind of a big deal about it because if they see the doctor cheating, then boy, that really gives the embezzler ... and I think, Howard, somewhere one in five dentist or embezzler, it may be worse than that. And so, the straight and narrow is just the way that they must go. In terms of compliance and risk management, they need to really watch that. 

One other point about people going to jail, this or that and with insurance companies, an insurance company that finds a doctor doing wrong can turn them into the board, that happens. And it's unethical conduct, the board can probe their license and so forth. And a lot of these situations, it's not jail per se but it can be a ding on their license, it could affect their malpractice, it could affect them. And so, they need to really think about that and try to go the straight and narrow as much as they possibly can. 

I want to say one last thing on medical. I burnt a couple of years generating this 623-page medical cross coding manual, medical dental cross coding manual with four medical coders. My knowledge of medical insurance was at ground zero, my knowledge now is way up there but not as much as my dental coding background. But anyway, on medical coding, let me say this, it's fake news to say medical pays everything, so you need to learn medical coding is going to pay all these things, that's fake news. To say that it's not worth learning medical coding at all because it just don't pay, that's fake news. So somewhere there is the truth. 

If you're going to get into sleep apnea, trauma, biopsies one thing and another TMJ, even implants and things, we're seeing better and better coverage on the medical side and it takes study though, but you do not have to go do a two-year medical coding training background in order to confidently turn in medical coding from a dental office. If you really apply yourself, you're willing to learn, willing to read, we've got a manual that I think is just dynamic for the medical coding. And that is coming in more and more. One other thing we're seeing, Howard, is that up to 10 states now, eight, 10 states are requiring on the dental claim. The dental claim has ICD-10 coding on it for four ICD codes. And so, we're seeing some of the Affordable Care Act plans requiring ICD-10 diagnostic codes. Also, some of the pharmacists are calling dentists in certain situations and saying, "I need a ICD-10 diagnostic code." So, you're going to hear more about this. 

And we may find, who knows, in five years, it may be that every dental claim going in is going to require the medical diagnostic codes. There's 72,000 codes and our book, we have sifted through that and we've got about 600 codes or whatever it is there that apply over to the dental marketplace. There's codes for getting bit by a turtle, there's a code for a knitting accident, there's a code of space station accident, it is wild. And so, I would just encourage every office to get someone on the business team that is motivated to learn medical coding, to get our resource and to roll up their sleeves and do a little bit of reading and see where they can go with it. 

Howard : So, again, you said medical billing ... if you're into sleep apnea, implants, TMJ, is that what you said? Anything else? 

Dr. Blair : Yeah, it's a number of things. And on the medical side, for instance, a cone beam. In dentistry, I can just put down a pan on a claim and get paid. The policy pays for a pan every three years, five years. But on medical, it don't work that way. On medical, it's got to an associated treatment. And so, for instance, if I'm taking out a tumor in the jaw, a cone beam would be paid. If the plan doesn't pay for implants, I'm doing a cone beam for implants here, it's not going pay for the cone beam. And so, the medical side of coin is covering more. As far as sleep apnea, that's also covered by Medicare. 

The big thing on sleep apnea, I think, is if you're going to do four-five appliances a year, stay away from it, it's not just worth it, the learning curve and handling the insurance and everything. On the other hand though, if you want to do 50 appliances a year which is easy for most offices with just minimal marketing, then, it is an area that they could certainly get into. But sleep apnea is a medical condition and snoring is just social. And so, sleep apnea is one though that is paid. What you watch out for though in the medical side, we're seeing more and more deductibles, co-pays, one thing and another and that affects, of course, the coverage for some of these services by a dentist. 

One thing that's paid often is newborn frenotomies. I saw a practice ... one of my clients did over a thousand frenotomies. It was a pediatric office but I've got a GP office that's done several hundred and newborn frenotomies are paid a lot of times because mama, she'd satisfied her deductible in the hospital when she had her baby and so, a newborn frenotomy for nursing, proper nursing is medically necessary and often, is paid. Get yourself tissue laser and you can zap that up for frenum, that lower frenum on a newborn baby and a tremendous little service and we see $600 fee or so for that. And also, patients will pay out of pocket, of course, to have proper nursing there out of the newborn. 

Howard : You said something very profound and I hope my homies heard it. You said if you're doing three or four a year, it's not worth it, but if you're doing 50 a year, it's always that 50 a year. It always comes down to one a week. I don't think there's any evidence for anybody getting good, fast, profitable, quality when they're doing a procedure less than once a week. So, if you're going to get into place the implants or sleep apnea or invisalign, if you can't reach a critical mass of one per week, you can't look at the efficiencies of a orthodontist student invisalign and think that'll transfer to you when you're doing three case a year. There's so many dentists that dabble in stuff, they don't realize that by the time they took all these courses, by the time they bought all these equipment, by the time they wasted all this time and then, they're doing this procedure one time every other month, it's a total loss. There is a critical mass to skill and pro ... 

Regina Herzlinger on her book, the Focused Factory, a medical economist showed that in healthcare, she [inaudible 01:31:00] with hernias, that the faster the surgery time, the higher the success rate. If you could do the entire operation in under five minutes, you have like 98% success rate. By the time it took you 10 minutes, you already have like a 5 or 10% failure rate. When you make one denture a year, it's the worst denture grandma ever had gotten in her life. You should have called an Uber driver and drove her to Denture World across town and paid for it. So there's that critical mass. 

Dr. Blair : I hadn't thought about that, I think you're absolutely right. I mean in the sense that when I made that comment, it's not worth it unless you do, but I think that's ... a good rule of thumb is you need to do one per week or four per month of something there to be really worthwhile. I think to have the skill set of the hands and the efficiency and then, if it's special handling insurance this and that like in the sleep apnea world, then, hey, you need to do about 50 a year. 

Howard : Yeah. And furthermore, what if you needed something done in healthcare, say you need an operation ... 

Dr. Blair : I would [inaudible 01:32:12] done them all the time, absolutely. 

Howard : ... would you go to someone ... I know. I mean if I was getting a surgery done, I wouldn't want some guy that does something once a month or every other month, I want a guy who did it the most. I want to ask you one last closing comment on macroeconomics because dentists our age are a very conservative bunch. I mean they're conserve ... Not a lot of liberal, hippie dentists in America over 50. When you learned all that medical coding and you said ... How many codes are there in medical, 60,000? 

Dr. Blair : Yeah, about 72,000 diagnostic codes and about 9,000 CPT procedure codes. 

Howard : Well, you know, after you're done doing that ... I mean if you go to an older 50 to 75 year old dentist and say, "What do you think about a single payer system?" He thinks you're a communist and you need to be shot and your next statement is, you're probably going to try to take his guns away from the NRA, but when you look at all that paperwork, I mean so many people say that the admin cost of the US healthcare system is about a third, about a third of the cost, it's just always there. We have the most expensive healthcare system in the world and it still doesn't cover everybody. 

When you were going through that journey, did it change your mind and belief of the American healthcare system? Do you think America has the best healthcare system in the world or do you think it's a very expensive system that doesn't cover a lot? When you were done doing that, were you thinking we should go to a single payer system like Germany or Australia or New Zealand or Canada or not? 

Dr. Blair : Well, boy, there's two sides to the coin there and when I see all of these bureaucratic paperwork, I think you're probably right. I bet there's 30% of it administrative. I think another point is that I've been kind of stunned just looking at a lot of reports, not that I'm a student of any of these by any means but that our healthcare is not really rated the best in the world and others, yet more bank to the buck, the person is living longer and so forth. 

And so, I don't know. As I look at it, I wonder about even the ... I see the way that the Medicare works and it has got some paperwork too when you go to the physicians' offices and so forth, but it's pretty doggone structured. I don't know. I'm not ... myself politically as I look at this, I see it kind of both sides of the coin in a sense, I can look at it, view it from either side, but this administrative overhead bugs me. I think that ways that we can be more efficient and less bureaucracy because our problem is, as you know, the inflation of the healthcare side is greatly higher than our other inflation aspects in our society. 

Howard : Well, I mean there's just so many structural problems like all of these doctors in hospitals are running about 4,000 different software systems. I mean you know like dentists, they're Dentrix, Hilsoft, SMARTDent, OpenDent, and the duplication of services because when they go from doctor to doctor, they're retaking all this stuff, enter in information. If you have a heart attack at the grocery store, when the ambulance guy gets there, he'll have no idea who you are, what prescription you're on, which doctors you're seeing. I mean the Taiwan model offers the same outcomes for the whole country, same outcomes as Mayo Clinic for $1,700 a year and we pay 17,000. I mean isn't that amazing? 

Dr. Blair : That is amazing, yeah. 

Howard : But when you say it to the America, I mean "America's great," "America's number one," "We're the best at everything", and the other thing that's funny is every single person who badmouths socialized medicine ... Have you ever noticed they're also the same people who have never left America one time? I mean when they say these, so they're like, "What the fuck socialized medicine like in Scandinavia." Dude, I'm pretty sure Denmark and Norway and Sweden blow doors on Alabama, Mississippi, and Tennessee and Arkansas, I mean I think they're some of the most advanced civilizations in the world. 

Sydney, Australia, every time I lecture there, on the 15-hour flight back, the first five hours on the plane back here, wondering why you're coming back. You know, but anyway ... But hey, I just want to tell you, I think you're amazing. I've heard you lecture so many times. We lectured together to some DSMO CEOs in Phoenix last time I think, we lectured together, weren't we? 

Dr. Blair : We could have been. 

Howard : Yeah. And those guys, corporates, they all listen to you. I mean those guys, when you're lecturing to the DSMOs, I mean all the big CEOs, all the DSMOs, I mean these guys take the business serious and today, you just got to take the business of dentistry a lot more serious. No one does it better than you. I hope you write some article or two for Dentaltown Magazine. I hope you do an online CE course because I think it'll be the best marketing you could do for all your books. 

Because, when they're seeing these courses in root canals, filling, and crowns and bone grafting, they just start drooling all over their shirt but someone needs to take them to school and say, "Dude, you got to pay for all this stuff," "You got to know your codes," "You got to know the business of dentistry," and you can't dump it on Myrtle up there because Myrtle is 60 years old, and no doctor has taken her to any continued education course for 40 years. Just because she's been a front office manager for 30 years, if no one's investing any time and money and resources into her, I mean she could be making the same mistake. 

Dr. Blair : Whose got one year's experience 30 times. 

Howard : Exactly. Exactly. And that's a different thing, when people say they're orthodontist, they say, "Oh yeah, those orthodontists get out of school, and they've only done 20, 40 root canals. I do that a week." Yeah, but you do your same root canal the same about 10,000 times over 40 years. And in those school, every root canal is ... Everybody's looking at it, everybody's talking about it, every one of them is a different case. You know what I mean? 

Dr. Blair : Exactly, yup. 

Howard : So, it's not even-steven. Again, Charles, thank you so much for all that you've done for dentistry, all that you've done for Dentaltown. I mean gosh, thank you so much for coming on the show today and talking to my homies. 

Dr. Blair : Well, Howard, thank you so much and also, I want to applaud you because what you've done and seeing you in the early days of Dentaltown and taking it to where it is today, it's just a tremendous voice and a tremendous forum for our profession and so, I salute you likewise. And thank you so much today. 

Howard : And by the way, when you were talking, I went to Dentaltown and we got that search bar and I like to show everybody out because that damn search bar cost me $50,000 to Google Appliance. I put in your name, Charles Blair. I mean it pulls up a hundred threads and you're like Open Dental. I mean all of your fans are raving fans. No one's ever posted, "That Charles don't know nothing about nothing." I mean everybody says the same thing, get Practice Booster, learn the codes, total value. So, if you don't believe me and Charles because you think we're just too old and senile, just go to Dentaltown and do a search for Charles Blair and you will find that he has raving fans thread after thread after thread. So again, thanks for coming on the show, buddy. 

Dr. Blair : Thanks again. My pleasure.