When it Comes to Patient Benefits, Knowledge is Key by Teresa Duncan, MS

Oftentimes the insurance coordinator is expected to be aware of all plan types and every benefit clause, while the patient will be unaware of the plan's intricacies—this is a certainty! Now, our job as health care providers has shifted to include affordability and convenience of the patient's financial portion of care.

Change is, of course, inevitable. But the constant changes dental teams face when it comes to patients' insurance benefits can be a bit overwhelming. In previous years, insurance coordinators were rarely caught off guard by a patient's benefits. Today, more than ever before, there is significant fluidity in plans and more limitations in frequencies and replacement clauses. These changes make it hard for even the most experienced of insurance coordinators to predict, with any level of certainty, how a patient's plan fluctuates from year to year.

When the team finds it difficult to keep up with the changing insurance landscape, they could incorrectly quote benefits and the patient's portion, which erodes patient trust and confidence in the team. Lack of confidence may cause the team to be less comfortable and confident discussing costs, payment options and benefits with the patient. This uneasiness is then transferred to the patient, both verbally and through physical cues, making them hesitant to accept recommended treatment.

Additionally, shared network changes and expansions have delivered an unexpected stream of new patients that the doctor may not be aware of or prepared for, especially in terms of having to abide by a lower fee schedule. These changes muddy the water and take away the clarity that used to exist. Your coordinators are struggling daily to identify which fee schedules apply to your new patient and to catch explanation of benefits with incorrect approved or allowed fees.

All of this has left insurance coordinators in an unenviable position. Patients expect the dental team to be as up to date on their individual insurance plans as their pharmacies and primary care physicians are. The difference is, with dental insurance, electronic eligibility is not available as readily as it is in medical health care practices. Because tracking changes in dental insurance requires increased effort, it's important the team understands the why behind the work.

Being as accurate as possible when estimating the patient's portion will prevent the practice from losing revenue on the back end. When you don't know the patient's responsibility or when insurance is underestimated, the team is left with no option but to bill patients after care has been delivered and chase money already earned. This, I believe, is not only frustrating for the entire team, but also a waste of valuable human and financial resources.

Knowledge Is POWER
When it comes to discussing treatment, insurance contributions and the cost of care, knowledge is power. Knowledge gives you control of your treatment presentations, financial conversations and cash flow. It's essential to know patients' benefits prior to their scheduled appointment. If their insurance eligibility is not readily available, use your practice management software to track how the different insurance companies typically pay—by plan and by employer. This can give you some level of predictability to present with confidence. For example, if when checking benefits, you find out that Plan A pays 100/80/50 but your software reflects that historically it has paid at 80/60/40, you then have more insight and confidence in the information.

If the patient is part of an unexpected shared network and the insurance coordinator is unable to identify the patient's benefits either electronically or through trends from their practice management software, quoting a range rather than a specific copayment is an option. The only caveat is that when quoting ranges, keep them as small as possible. Broad price ranges tend to confuse patients, and confused patients rarely accept treatment!

The best way to confidently present insurance benefits is to set expectations with the patient. If the plan is familiar and one patients frequently use at your practice, the conversation may sound like this:

"Mrs. Jones, I've dealt with your insurance plan several times, and I'm very familiar with the amount they estimate for care and the amount they actually pay. I know the number I am quoting you is as close as I can get to the actual amount your benefits offer. I do this every day, Mrs. Jones, so I'm confident in this amount. But, if your plan has changes, which they are doing quite often these days, and I find out that this is not correct, I will pick up the phone and call you so we can work this out together."

Conversely, if the plan is unexpected or new to the practice, let the patient know:

"Mrs. Jones, this is the first time we've worked with this particular plan. Although I'm confident in the amounts I am quoting you, I'm going to do everything I can to find out what we're looking at in terms of your copayment amount. Please be aware that sometimes I get surprised and if that happens, you will be the first to know. I will call you and we will work this out together."

The key is to let patients know that the team is confident their benefits and patient portion can be worked out and that the focus is on enabling patients to get care.

Knowledge Is CONFIDENCE
Part of the catalyst behind the changing insurance landscape is employers' drive to save money which often leaves patients with an increasing out-of-pocket investment. So, in addition to having reliable information on the patient's benefits, presenting treatment confidently also requires having payment options that enable patients to proceed with needed, recommended treatment. The last thing you want is the patient accepting treatment that is only covered by insurance because they don't have an immediate way to pay for their portion.

When discussing insurance, fees and payment options, start by immediately sharing the patient's responsibility.

"Mrs. Jones, the treatment the doctor recommends to get you healthy and help keep your teeth for life is $1,500. The good news is, we're estimating your benefits will contribute $800 to the cost of your care. That means your portion of the cost of care is $700. That's much better than $1,500, isn't it?"

After sharing the patient's portion, stay quiet and let them respond. There is no need to immediately jump in with solutions because the patient hasn't expressed any concerns that need solving. If the patient responds with what I call "the look" or immediately expresses cost concerns, then it's time to empathize and provide payment options.

"Wow. That's a lot of money. I wasn't prepared for that. I thought insurance would cover everything."

"Mrs. Jones, I understand your concerns. Many of our patients are not aware that their benefits have most likely changed and that the portion of care covered is less than it may have been in the past. We do have a way for you to break down that $700 into more manageable payments, possibly less than $150 a month. Are you okay with me talking to you about that?"

If the patient responds that a monthly payment would work, then it is time to schedule the treatment. But if there is additional pushback, it may be that they are not clear about the treatment and its benefits, are fearful, or have another obstacle that must be addressed. Or, quite possibly, the patient wants to take time to think about it. At this point, it's important to gain permission to follow up with the patient and then do so within two to three days. Keep in mind that a patient's refusal of treatment is not a one-time disappointment. Offering a second consultation or following up by phone can provide another opportunity to help the patient get the care they need.

"Mrs. Jones, I want you to be comfortable moving forward with the treatment the doctor has recommended for you. May I follow up with you in the next few days so we can talk about treatment a little further?"

Knowledge Is CONTROL
Another way to stay ahead of the curve when it comes to patients' insurance benefits is to educate patients and encourage them to come in to take advantage of their benefits throughout the year, not just at the end of the year with "use it or lose it" messaging. On a quarterly basis, reach out to patients and remind them they have benefits available. It seems in the fast-paced lives we lead, making time for dentistry is becoming less of a priority.

Part of the dental teams' responsibilities is to make sure patients are aware of the necessity of ongoing dental care. Rather than reaching out to just hygiene patients, let's contact those patients who have not returned after comprehensive evaluations or treatment consultations. Schedule your software to send messages to these patients on a regular basis and invite them to return.

One of your messages could include something like: "Remember the insurance benefits we discussed? They're waiting for you! Contact us today to set up your appointment." Your messaging should be clear (your benefits are ready and available) and confident (we're ready to make that appointment!)

Insurance coordinators who feel good about the information they're sharing with patients will be better at their job. That confidence will show in their conversations and treatment presentations. The rule of thumb is that the plan you are discussing today could very well be completely different in one year's time. The flexible insurance coordinator will expect plan changes and be ready to communicate them to the patient and the team. The new norm is that the insurance industry is constantly changing. Your patients will expect you to navigate these changes and clearly communicate what it means to them. With confidence and clarity, your team can say to your patients, "I can help you with your benefits."