Cutting the Coverage Cord by Dr. Elizabeth DiBona

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Categories: Practice Management, HR and Accounting;
Cutting the Coverage Cord 

Five surprising shifts after going fee-for-service

by Dr. Elizabeth DiBona

Let’s first define what a fee-for-service practice means, at least in my practice: Fees for services rendered are due in full on the day of service. If the patient has an insurance card, we collect that information and I have an employee send out the claim form. My fees are higher than what insurance allows, and usually the patient gets back what their insurance is willing to pay for an “out-of-network” dentist, in the form of a check mailed directly to them. Thus, our production is our collection at the end of each day. There is a bit of nuance to this, as I discount services for our membership patients, so there are “write-offs” for that, and we also provide care for our employees and employees’ families, and those get written off. But for the purpose of discussing fee-for-service, production equals collection. Patients pay in full on the day of service—no chasing payments.


Going fee-for-service
Many colleagues ask me, “What made you decide to drop insurance?” I’m not sure if it was one thing, but more like a culmination of things.

The insurance hustle kept me so busy with patients (and making decent money) that I didn’t have the time to even strategize my career path. The pandemic provided more time (and an incredible amount of stress for me) and I felt the game had changed. Of course, I didn’t really have time to do any real planning during the pandemic, but I think that was the shift I needed.

I was mulling over the following:

Resentment: Dentists take on all the risk, all the physical toll of long procedural days, all the mental strain of keeping patients pain-free and happy, and I started to resent insurance corporations for having such control over us. I wasn’t opposed to working with insurance corporations; however, I resented the fact that they controlled my fees. I couldn’t control quality of care, materials, or labs without controlling fees. My body and mind were becoming fatigued, and I wanted to take control of my future career.

Awakening: I started listening to the “Less Insurance Dependence” podcast, (which is free) and I started to see an entire picture of me thriving without depending on the so-called “middleman” of the insurance world.

Planning: I set my goals, put them down on paper, involved my team and used everything I learned from podcasts and blogs. After six months, I dropped Delta Dental, which was the only insurance we were contracted with.


Three years later
Now, after being a completely fee-for-service practice for more than three years, here are some take-home points.


1. Time
You will have more time! A full workday is slower-paced, more focused on each individual patient, and the revenue is better. I see openings in my schedule, and of course at first that made me nervous, but now I see it as “Oh, we have time to scan for the occlusal guard for that hygiene patient,” or “We have time to take more photos of our new patient for better case acceptance.”

It feels rewarding to have time to add on emergency patients, because as dentists, we have such specialized skills to help patients avoid the urgent care, and directly address their dental emergency. I feel valued, and patients often express their gratitude.

Case acceptance goes up with more time. I take more photographs, I do more cosmetic cases, I have more time to treatment-plan larger cases. I’ve learned about the different software to do photo mockups for patients (right now we use SmileCloud), and our practice has really adopted a great digital workflow.

Time has allowed for more adjunct procedures too, like Botox and PRF microneedling, and although that is not a big profit-maker in our practice, working outside the mouth is about 1 million times easier than inside the mouth—and the appointments are fun. My team enjoys the facial cosmetic part of our practice (both helping deliver that care to patients, but also being patients themselves!)

Time also allows me to give back to the community. I do about six free arches a year of dentures (and I use my same expensive, wonderfully talented lab technicians to make them movie star teeth!). I have worked on women who are the victims of domestic violence and have suffered tooth loss. I have worked on members of our community who are on welfare and cannot afford our fees. These patients are incredibly grateful, and it makes me feel good being able to give back to my area.


2. Patient attrition
Yes, many patients will leave your practice and search for someone “within their insurance network.” We had about 10% attrition, which was about what we expected.

Many of these patients—interestingly—seem to be medical physicians. I think there are two main reasons why a fair number of them left after I switched to a fee-for-service model. First, many physicians, especially younger ones, have a lot of debt from medical school. They’re often overworked and possibly underpaid, considering the sacrifices they’ve made. Second, most physicians have a limited understanding of the insurance industry, and even less understanding of how dental insurance works. So they likely figure it’s all the same and choose a dentist who is in network. Of course, some do circle back and bring their entire families into our practice because they appreciate the individualized care they receive.

Which leads me to this: I tell patients, if you ever need to come back to my practice, you are always welcome back. In fact, we often get patients who try out another practice, and circle back around to us.


3. Marketing
Social media is a helpful marketing tool—and it’s time-consuming to master. Yes, you can hire someone to help you, but if you don’t generate original content that is genuine and useful to patients, it won’t generate leads.

As we’ve grown independent of the insurance model, we’ve learned how to better showcase our practice on social media—through many hours of observing successful accounts and actually practicing creating content ourselves. I am by no means a master, but after a couple years I feel like I’m starting to get the hang of it.

There are some great courses out there for dentists. The one I am using is called Leverage: Social Media for Dentists, by Joyce the Dentist. She’s amazing—I really admire her content and her course for dentists.

Part of marketing is being likeable. Patients must like you, must like your team, and they have to see the value of the care they are receiving. It can be simple customer service techniques like using their name, making sure they have a neck pillow, handwritten correspondence to thank them for referring someone to your practice, a warm towelette after a procedure, etc.

We have also created an in-house membership plan which my older patients and small business owners love. Recently we updated it to include a $50 activation fee which is waived when they first sign up. This was to discourage signing up and then stopping it for six months until they need their next cleaning. Also they pay for the entire year up front, not monthly. This encourages patients to keep their scheduled preventive visits.

Another thing we offer is third-party financing. We offer two options for patients, which come in handy for large cases. I strongly suggest if you are considering going fee-for-service, you consider working with some third-party financing options.


4. Continuing education
I have more time to do continuing education and really dive into areas of dentistry that excite me. I also have had more time to try to master dental photography, which I think is such a useful tool for dentists. Not only is it helpful for marketing and case acceptance, but it really helps me become a better dentist. There’s nothing like seeing your work framed by the patient’s face to help you hone your aesthetic skills.

I had the time to take a week off to go to the Kois Center in Seattle last year, and I found it a rewarding and a highly educational experience. I go to the American Academy of Implant Dentistry conference every year and enjoy connecting with my colleagues. I’ve done a dental photography course in Boston twice now, and even brought my assistants, who do more photography than I do these days! We all have had time to do PRF training and phlebotomy training. All these things inspire me and keep my team engaged as well.


5. Patient pushback
Yes, you will still have haters. Patients will get frustrated. It’s incredibly stressful financially for many patients to front the cost of their dental care and await insurance reimbursement, and they will likely express this frustration to your administrative team after you’ve left the room. I’ve realized it’s OK to not be “everyone’s dentist.”


Why do I share my fee-for-service story?
I share because it’s in my nature—but also because I hope that when I’m 75 years old (I’m 46 right now), there are still high-quality, independent dental practices out there to take care of me.

If we’re truly in a “race to the bottom,” as some colleagues have said, then there have to be dentists who see another path—one where we take back control and remove the ability of insurance to dictate fees and influence care. That’s my intention here: to encourage some doctors (not all) to explore whether this might be the right move for them.

My opinion is that insurance is a middleman, and I often wonder what dentistry would look like without it. My grandfather and father—both dentists—practiced without insurance, and their patients still received affordable care.

And just when you may need an extra bit of encouragement, remember—we’re not MDs. Dentists have much more control over their field, unlike many of our medical colleagues. We are problem-solvers at heart, so explore it and see if it’s right for you.
Author Bio
Dr. Elizabeth DiBona Dr. Elizabeth DiBona received her bachelor’s degree from Brown University and her DMD from Boston University School of Dental Medicine, where she graduated magna cum laude. She completed an advanced general dentistry residency at BU. She is a third-generation dentist. DiBona’s practice in Exeter, New Hampshire, combines an assortment of specialists into a robust, 4,000-square-foot multidisciplinary office. A diplomate of the American Board of Oral Implantology, she has amassed more than 1,000 hours of continuing education credit hours and a growing collection of implant accreditations.
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