Your dental insurance company has never met you. So why do you value their opinion?
I remember as a child going to the dentist religiously once every 6 months for a cleaning and checkup.
Every time I would go in to see the hygienist, (Laurie was her name, and I think she may have been my first “love”) I would hear, “Kelly – you’re doing a great job. Keep up your great home-care. Your teeth look wonderful”.
During 20+ years on my parents’ insurance plan, I would see the dentist consistently despite the fact that my teeth were always clean and that I had no cavities.
The dental insurance company (with whom my father’s company held a contract) would pay the bill and I never gave it a second thought.
No Risk? No Problem.
Knowing what I know now as one of Portland’s premier dentists, I see the pattern:
No risk – no major cost to the insurance company – no problem.
The insurance company paid without question. However, now that I am on the provider side of the equation, I am seeing how “dental insurance” companies really behave.
I will warn you now: it may shock you.
My Tipping Point
In the past year, I have had some unbelievable experiences with dental insurance companies. It has gotten to the point where I am compelled to share my experiences. In fact, it got so bad that after years of being an “in-network” provider with a few “dental benefits providers”, I had to sever my ties with them. This was a very hard decision to make.
As a caring and compassionate human being, I want to use my education and experience to help people achieve their best level of oral and systemic health. Unfortunately, dental insurance companies are not set up to accomplish the same goal.
Recently, I was having dinner with a good friend who has worked in finance for 20+ years and is an assistant CFO at a large international corporation. I asked him “If you were trying to increase the profitability of your company, what methods would you employ to make your company look its best?” One of the first things he mentioned was “Delay payment.”
His answer hit me like a bell-a-ringin’!! Let me provide an example:
In October 2016, I performed gum surgery to cover the exposed root of a patient who experienced pain and sensitivity for a few years. She could no longer chew in that area. After all of her options and risks were discussed, she chose to have me use the Pinhole Gum Rejuvenation technique to cover and protect her roots.
The surgery went well and this patient’s symptoms were resolved. AND this was a “covered procedure” based on the definitions of her dental plan. Now, to be clear, my recommendation of this care had nothing to do with whether it was a covered procedure or not. I simply recommended the procedure that I felt would resolve this patient’s problem (which it did).
And then the problems started…
After my front office compiled all of the supporting data and submitted the claim to this patient’s insurance company, we then receive back a letter stating that they are denying the claim.
First, they stated that they did not receive enough supporting information (delay of payment #1).
So we clarify. We sent:
- Periodontal charting
- Treatment notes
They said, “No, we didn’t receive those. Please resend them.”
So we do. Keep in mind that one of my employees now has to be paid to manage all of these communications and the shuffling of information. After more waiting, we get another rejection (delay of payment #2).
The insurance company says, “Our claims advisor does not feel that there is enough supporting information to support this claim. Therefore, we are denying this claim”.
Now for a moment, please consider this: No “claims advisor” at this insurance company has ever met or examined the patient that I am seeing. Yet somehow they get to pass judgment on what is and is not appropriate care. Does this make any sense??
But I digress…
My front office team shares with the patient that her insurance company, despite all of our supportive documentation, is denying her claim. We recommend that she call her insurance company for further clarification as we are getting nowhere. At this point, more than 4 months have passed since the surgery AND the patient is feeling well and her symptoms have resolved.
Over the next 3 or 4 months, the patient made calls and got the runaround about why the insurance company is not paying.
After 8 months (8 months!!) of the insurance company holding up the claim, I ask my insurance claims supervisor to put me in direct contact with the lead supervisor who is in charge of this claim. We set up an appointment for a conversation.
I was to speak with this supervisor at 2 PM on a Friday. Then “miraculously” on the morning of the day where I was to talk with this “dental claims expert”, my insurance claims supervisor receives a call from the insurance company.
This is what they said:
“It appears that the claim that you submitted has been “re-reviewed” and is now in process for payment. Would Dr. Blodgett still like to speak to our Dental Claims Supervisor?”
How messed up is this??
A company who has never met my patient is allowed to be in a position where they can determine whether payment is rendered for services. Yet they have never performed an exam on this patient.
This makes ZERO sense at all!
They were able to hold up the claim for almost 9 months. This means greater profitability for the insurance company. Despite how ridiculous this scenario sounds, I constantly hear from patients who say “Will my insurance cover this?”
Honestly?? What does your dental insurance know or care about your health? I will tell you what they know – how to increase their profits by not paying on your just claims! But they’re given the purse-strings to your health benefits?
It is insanity.
Don’t Allow Insurance to Dictate Your Care
Please – if you care about your health, do not allow an insurance company (who has never met you) to dictate your dental care. An insurance company’s #1 objective is to be profitable.
This WILL mean that they try to not pay on just claims. Yes – it is totally wrong and unethical (in my opinion), but it is what they do. And either you or your employer are paying them to do it!
Will you allow them to control your health choices?
I have more stories to share along this line but need to get back to being of service to people (not ripping them off like insurance companies do). I look forward to sharing more such stories in the future to shed light on this important topic!
Kelly J. Blodgett, DMD