Question: How can I explain to patients to pay for their limited exam out of pocket so they don’t use up the periodic exam? I would like some tips on how to approach patients when it comes to paying out of pocket.

Answer: It is important to know and understand your patients insurance benefits to educate, support and give accurate treatment plan estimates. The information that you receive when getting a breakdown of benefits should not be used to dictate a course of treatment for a patient. Regardless of insurance frequency and limitations, your ultimate goal is to provide the best service for your patients dental needs. As a provider of service you must always make the insurance company aware of any services performed for a patient. All services must be submitted to the insurance company and then the insurance company evaluates the services performed and pays the claim accordingly. Clearly communicate with patients about what amount of the payment they are responsible for if the insurance does not cover the estimated amount. The information received when getting a breakdown of insurance benefits can certainly assist and help your team when explaining patient balances. If your patient has further questions regarding their particular insurance policy always direct them back to their insurance company and employer for further explanations. Being insurance savvy is a huge value to your patients but looking out for the best interest of the patient and their dental needs comes first.

1. Check a patient’s eligibility– Get a full breakdown of benefits for all new patients or anytime patients change insurance. Be sure to also check electronically for all recare patients to make sure they still have active insurance. Ask patients about coverage changes at recare visits or any time there might be a concern. Know what questions to ask when calling insurance, and make sure the software gets updated correctly. Ask about things like waiting periods, missing tooth clauses, downgrades, etc.

2. Get a Payment Policy/ Treatment Plan Signed by Patient– Clearly communicate with patients about what amount of the payment they are responsible for if the insurance does not cover the estimated amount.

3. Submit the Claim with Correct Service Codes and Providers– Make sure what was completed was coded correctly and with the right provider before you submit the claim. Mistakes in this information can delay payment. Bill what procedures you actually do, regardless of what the insurance company says. It is insurance fraud to bill for anything except the actual procedure. Send the narrative and necessary radiographs to have the highest probability of getting paid in a timely manner.

Remember: You may have to deal with insurance, but you do not work for them.

You are here for your doctors and your patients. Understand that patients will not be happy when the insurance does not pay what is expected. It is ok to empathize with them. Let them know you understand that it isn’t ideal but ultimately, if they have a problem with their insurance, they need to discuss that problem with their employer. Your goal is to help them maximize their insurance if you can, but at the end of the day, you are there to help them keep their teeth for life. You are their healthcare provider.

Patients First, Insurance Second!

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