For both the patient and the provider, dealing with insurance companies that overpromise, overcharge, and ultimately underdeliver is a supremely frustrating experience. In this article, we hope to address some common problems insurance companies cause their insured. Moreover, we explain what we are doing in our office to diminish the insurance headache for our number one priority — our patients.
Years ago, health and dental insurance providers charged monthly premiums that varied in price based on the coverage promised. As time has progressed, insurance companies have drastically hiked the monthly premiums their customers must pay. However, the coverage (the deductible, annual maximum, and percentages) that insurance companies provide has remained stagnant, or even worse, has diminished. This increased cost to customers with no corresponding increase in coverage is troubling, to say the least.
Unfortunately, most insurance companies are simply unwilling to provide full coverage for advanced treatment from a specialist. In fact, insurance companies typically deny even partial coverage unless faced with staunch opposition. This refusal is in spite of the fact that many people in dire need of periodontal treatment pay expensive monthly premiums for coverage that their insurance providers immediately attempt to avoid paying.
Moreover, insurance companies have numerous telephone representatives who make promises of coverage to unsuspecting patients who take these phone representatives at their word. The sad truth is that you could call, speak to an insurance representative, and be assured of coverage for your next appointment. Yet you could call the same number minutes later, speak to a different representative, and receive an utterly different answer to the exact same question. This is as infuriating for us as it is for you.
It is especially frustrating that insurance companies attempt to cast blame for their inconsistencies upon health care practitioners when, in reality, the insurance company is the one engaging in double talk and false promises. When a patient is upset because his or her insurance company did not pay for a treatment that an insurance representative assured would be covered, the one responsible is not the physician or dentist who is simply trying to provide the best treatment possible — the one responsible for refusing coverage is the entity that refused coverage.
That is why at North Raleigh Periodontics we bend over backwards to do everything we can to make sure your insurance company actually provides you the coverage it promises. Some private practices will not do this for you. But our office sets itself apart in many ways through our efforts to make the insurance and payment process as seamless for you as possible. Some offices will not even file your insurance claims as a courtesy to you; instead, the mindset towards insured patients is often: “it is your plan, your coverage, your contract with the insurance company. The most we can do is accept your insurance, but the rest is up to you to handle.”
However, at North Raleigh Periodontics we endeavor to make your experience exceptional from start to finish, from exemplary treatment to dealing with even stubborn insurance companies so that you do not have to. You come to us to be treated, not to single-handedly take on an insurance company without assistance. First, at least two days before you enter our office for your scheduled appointment, we spend hours in communication with your insurance company, figuring out exactly what your insurance company purports to cover for you.
Moreover, if you have a larger procedure scheduled, our interaction with your insurance company begins sometimes months in advance. We provide your company with all the necessary information to obtain a “pre-treatment estimate” on your behalf. This estimate is a statement of what your insurance company says it will cover — unfortunately, this is as close to a promise of coverage as an insurance company is willing to give. Luckily, insurance companies usually honor the amount they say they will pay in the pre-treatment estimate, so you can go into your procedure with a close idea of what your company is willing to cover.
Another aspect of our approach that distinguishes us from other practices is our efforts to protect you from paying more than you need to. Unlike many practices, we do not require payment in full upfront. Instead, we only require the amount that your insurance company likely will not cover. However, our team will never — and should never— “guarantee” for you what your insurance company will cover definitively because even multiple insurance representatives from a single company are seemingly unable to do so. But to the best of our ability, we work to determine what your part will likely be so that you do not end up paying an exorbitant out-of-pocket expense.
Some offices do require patients to pay full price upfront, with patients getting minimal insurance reimbursement to offset the out-of-pocket expense weeks or months later. Such a process disincentivizes an office from haggling with the insurance companies to get them to provide the coverage for which patients pay so much. However, we spend a great deal of time communicating with your insurance company before and after your treatment — we do not simply file your claim one time and then give up when your company perfunctorily denies the claim. Instead, we work hard to create a cogent narrative explaining in detail exactly what procedure you had, why you required it, and why the respective insurance company should honor its contract with you. Moreover, we spend time and resources satisfying insurance companies’ demands for documents, records, x-rays, treatment histories, and whatever else they feel is necessary before they will fulfill their contractual obligations towards you.
Unfortunately, some patients have difficulty understanding that their company simply will not cover certain necessary treatments. This is understandable since the point of paying expensive premiums is to actually obtain financial coverage for these crucial treatments. It, therefore, seems baffling when your periodontist, often your general dentist and even your primary care physician have told you that you need periodontal treatment, yet your insurance company refuses to cover it. Even more frustrating, when patients ask their insurance company why their coverage was denied, representatives sometimes falsely inform patients that the company did not receive the necessary clinical information (x-rays, charting, and narratives) when in fact we are able to track every piece of information we send to insurance companies and can verify that the company has, in fact, received the information.
Finally, representatives like to tell insured individuals that their health care practitioners are the ones delaying their coverage, or neglecting to send in the required information. It serves no purpose for us to delay treatment or withhold any information that would allow insurance companies to consider the claim. Doing so would simply prevent us from providing you the treatment you need, benefitting no one except the insurance company.
Even more regrettably, sometimes patients choose to only undergo periodontal treatment to the extent covered by the insurance company. This is lamentable because patients often come to our office specifically because they have some issues that a general dentist would prefer a specialist such as Dr. Singletary to examine and treat. When patients decide that they will only get the treatment their insurance company fully covers instead of the recommended course of treatment, patients absolutely run into greater, more expensive health problems down the road. Yes, it can be costly, and it definitely can be frustrating when your insurance company denies coverage, even after we have exhausted all resources on your behalf. But it is even worse to tailor the doctor’s treatment plan for you based only on what your insurance plan chooses to cover. Doing so will only intensify already acute periodontal issues since insurance companies often will not cover what you need.
To conclude, our number one priority is our patients’ health and wellbeing. That is why we come alongside you as your right-hand man to do everything possible to get you the coverage for which you pay a monthly premium. It is important to remember we are on your side — instead of filing your claim just one time or maintaining the attitude that it is your contract, your insurance company and therefore your problem, we work with you to hold your insurance company accountable.
Moreover, instead of requiring payment in full upfront, we spend hours, days, and sometimes months communicating with your company to find out (1) what will be covered; and (2) fighting for you to actually receive that coverage. That way, we only charge you what your insurance company will not cover. Unfortunately, insurance companies routinely deny claims anyway, despite promises and contractual obligations. But that is where we again come alongside you, fighting for you until we get a straight answer as to why you were denied coverage and until your insurance company does what it says it will do.