Episode 145: 3 Insurance Nightmare Stories

Naren: Hello everyone welcome, to the 145th episode of the less insurance dependence show. This is Naren, your co-host. This is the official podcast of the reducing insurance dependence academy, rid dot academy. Today’s topic is three insurance nightmare stories before. I jump into today’s topic; I have a quick announcement to make. We have an upcoming master class. It’s titled specific plan to reduce your overhead to 60 percent or a less specific plan to reduce your overhead to 60 percent or less august 25th, 7 to 10 pm eastern time; this is a master class that we did seven or eight months ago, and we got a lot of people saying can you please repeat it because they couldn’t make it, so we wanted to bring it back it’s one of our top masterclasses so if you haven’t you know been part of it definitely sign up three hours of CE very affordable we made it less than a hundred dollars go to thrivingdentist.com forward slash masterclass, thrivingdentist.com forward slash masterclass. Now three insurance nightmare stories. Now you might be wondering why we’re talking about this. Just recently, Gary was sharing with me a story uh that was related to him by a new client, a specialist client who signed up with his coaching program, and he was talking about like you know enough is enough where this dentist finally said I don’t want to take this anymore. So, Gary, let’s jump into today’s conversation.

Gary: Yeah, Naren, let me just start by speaking to the obvious; Naren, news flash. The dental insurance companies don’t care one little bit about the dentist. Now that is perhaps the understatement of the year. Would you agree?

Naren: I agree 100 percent

Gary: they don’t care one bit about the dentist now we’ve known that, but these three nightmare stories are going to punctuate it. So doctors, as you’re listening to this, be sure to take some deep breaths and don’t let your blood pressure rise too much but let me know if you can identify with any of these nightmare stories. The very first one, as you mentioned, was a new client of mine. In the past, this new client was able to contact the insurance companies and advocate for the patient, advocate for benefits for the patient, and you know to be quite honest with you sometimes he was successful with this and sometimes he wasn’t, but you know the insurance companies have what they call dental consultants. Their non-practicing dentists work for the insurance company, and in the past, this doctor was able to contact the dentist consultant and make his case. Say hey you know, get his name and say hey, can I talk to you about this case and, and, you know this is one that I think you know should be covered under the insurance policy would you review it and you know let me know if, if, you’ll provide coverage and a fair amount of the time, it was successful. Now Naren, you might be asking yourself, well, why would this be successful? I don’t know; the truth is I don’t know. Maybe it’s the fact that it’s a doctor-to-doctor conversation.

Naren: I think that might have a lot to do with it because perhaps the doctor once upon a time would have dealt with something like this, and he’ll put himself in the shoes and say, you know what, yeah, you know if I was a doctor, I would want this covered too 

Gary: and maybe it was because so few dentists ever do this 

Naren: right 

Gary: you know maybe, maybe, this consultant is sitting around bored to tears no one ever calls him and, and, you know and has, has, a conversation with him about a particular case and the few that do maybe he figures well what the heck I think we could make an exception this time. Well, here’s what happened and this; I’m not going to name the states because we didn’t have permission, we didn’t ask permission to do this but let me tell you what happened. An entire state, and this was, a delta claim, I will mention the culprit it was a delta insurance claim. In this particular state, delta has now outsourced all of the claims, processing to two different states. So, they’re getting out of the claims processing business.

Naren: even though that’s their business 

Gary: that’s their business, so they’ve outsourced it to two different states that now those states do their processing for this state. Now there I’m scratching my head, trying to figure out how in the world. 

Naren: imagine a dentist saying I’m going to outsource all my dentistry

Gary: I guess outs maybe they read an article in the wall street journal that said outsourcing is the thing to do; you know it’s something outsourced. Well, now this doctor specialist, in this case, there is no way for him to contact a consultant in the two states where they’re handling the processing. There is; it’s just you’re out of luck. He’s tried every which way because frankly, as I mentioned, he’s had success before he’s tried every which way, and there is no way to do that. That’s my first nightmare. Now how’s that for, for, a nightmare story 

Naren: so, in other words, there’s no human to talk to. You’re just talking to a wall. 

Gary: there’s no way yeah no, it’s like calling google 

Naren: right 

Gary: I, I dare you to call google

Naren: Right

Gary: it’s not possible 

Naren: it doesn’t exist 

Gary: it doesn’t. I don’t think they have any phones 

Naren: yeah, I don’t think so

Gary: so, I mean, talk about a nightmare, and this doctor was so frustrated. He said Gary, it didn’t work 100 percent of the time, but I didn’t mind spending some time on this because on occasion, we would get some nice coverage and on when to advocate on behalf, you know, on the part of the patient. He even said that I had a particular consultant I could call his direct line to, and you know we kind of developed, you know, some rapport, and I found them to be very helpful. Well, all that’s now done, over. 

Naren: Gone

Gary: gone doesn’t happen anymore okay, that’s nightmare story number one. Now nightmare story number two and Naren, this is something that we all know, but I want to punctuate it in most general dental offices; you know, the typical re-care, I like to use the word re-care instead of recall. I think the words we use are important. The recall is something Detroit does for bad cars.

Naren: yes

Gary: so, the re-care cycle for healthy adults is every six months. Now many, of all, insurance companies put a clause in there that says that if the patient shows up for their next hygiene appointment before the six-month interval, it will not be covered, right are you familiar with that clause, Naren?

Naren: yes 

Gary: so, if the patient shows up five months and 29 days after their last hygiene appointment, this one gets stamped denied. We all know that, right 

Naren: right 

Gary: right now, let me tell you why this came up; there’s still more movement going on in hygiene right now, and I’m talking about in the time that we’re recording this and the time that it’s being aired there’s way more movement happening in hygiene than ever before, and it’s still kind of a by-product of COVID even though we’re working our way through covid. People are getting tested, and it’s like, well no, I think I might be positive, so I got to reschedule this sort of thing, and openings are happening, and team members are working very carefully to fill those hygiene appointments. Well, again, this happened with a particular client of mine, general dental practice.

Naren: right 

Gary: and he called me to say, you know Gary, we know about that six-day wait or six-month wait we know about the six-month interval, but my hygiene scheduling coordinator has been working so hard to fill any openings in hygiene that she actually wasn’t paying attention to the six-month interval and she said my client said we went ahead and scheduled some patients that were like a matter of a few days early a few days 

Naren: that’s crazy 

Gary: you know, so we’re not talking about months early

Naren: Yeah

Gary: we’re talking about a few days, so it was five months, and you know 22 days, five months and 28 days 5 29 days, and so the office manager decided to call the insurance companies and advocate for the patients. Look, it’s very close to, to, six months. Is there anything you can do to make an exception? You know well, we’ll pay better attention to it, but my hygiene scheduling coordinator has been working her tail off to fill the openings in hygiene. Would you because you can look at our past history, this isn’t something that comes up very often. Would you be kind enough to take a look and see if you can make exceptions this time? It was a handful of patients, Naren.

Naren: Right

Gary: it was six or seven patients. Can you guess what the insurance company said? 

Yeah, I think I think the answer is nope. 

Gary: Nope, you’re out of luck. It’s, it’s, hard and fast. I have no wiggle room. Nope well, you know.

Naren: I know

Gary: That was the end the end 

Naren: ridiculous, right I mean, who’s serving who, who, is the boss here, who’s the customer here? He was just 

Gary: what we did do in this case Naren though the office manager contacted the employer, and there are actually two or three different employers 

Naren: right 

Gary: they contacted the employer and asked to speak to the executive in the benefits department they-she explained this to the benefits supervisor, and the benefits supervisor was, was, not happy. She just said that it doesn’t serve our employees very well, does it and you know our answer was no we wanted you to know this so that when it’s time to renew this contract, you might want to look at other carriers because this is what we bumped into with your, your, employees. Now whether that goes anywhere or not, I don’t know Naren, but at least we serve notice to the person in charge of making decisions about buying policies in the future, and maybe they’ll choose to go with another carrier next time. 

Naren: and I think the other thing is, you know, a lot of people missed a lot of hygiene right during the pandemic. So, some may have periodontal disease, some may have challenges, and so it’s not just even like you know hey, it’s just a few days, but it’s patient. 

Gary: we’re seeing patients in my life smiles practice there and that their last appointment was before march of 2020.

Naren: right 

Gary: you know, and at the time of recording this, you know that’s now 15 16 months, and oh and by the way, do you think the insurance company issued refunds for patients that didn’t go to the dentist No

Naren: no, and now you have developed periodontal disease, and you need to go two times, or you know every five months then they’re not going to pay for that either it’s just 

Gary: well, the height the, the delta insurance company, you know sadly they don’t care whether the patient develops the periodontal disease. In fact, this will sound odd, but many will actually appreciate that because many insurance policies have no periodontal coverage at all. There’s a perio exclusion clause. So again, this shows how we’re fighting a nasty battle about an entity that doesn’t care one bit about your patient’s health, doesn’t care one bit. Now let me go to the third one and, and, the third one is, is, really a note of caution Naren, and I want to send out a big note of caution. One of the things that I feel very strongly about that is wrong in the way dental insurance works today it’s wrong is that many services that we provide in our practice simply aren’t covered by exclusion because there’s an exclusion clause in the contract. For example, cosmetic dentistry is not covered. However, if you’re a participating provider, you have to submit fees even on services that aren’t covered, and you have to subscribe to their contracted fees, even if that’s a service that isn’t covered. Does that make sense, Naren?

Naren: can you explain that again, Gary?

Gary: so veneers, not cover you get paid zero 

Naren: right 

Gary: you should be able to charge your usual and customary fee for veneers 

Naren: right 

Gary: because the insurance company has no payment participation

Naren: right. I mean, if they don’t participate, you know absolutely zero 

Gary: zero; however, if you’ve contracted with them, you have to submit your fees for veneer, and you have to accept the contracted fee even though it’s not covered by insurance 

Naren: and that’s typically 40 or 50 lower than what the usual fee is, right 

Gary: it’s often more like 50 percent lower, so if your veneer fee was, was, 500 it might be paid at, or excuse me, veneer fee was, was,1200 it might be paid at 600. Even though the insurance company has no participation in that 

Naren: right 

Gary: so one of my clients said, Gary 

Naren; its like mafia; it’s like you know they they

Gary: Oh yeah, it likes protection

Naren: How to run your life

Gary: Its protection,

Naren: Yeah

Gary: I mean, it seems to me like the logical solution here would be if it’s not covered under the policy, you can charge your usual fees; however that’s not, they’re, they’re, literally like taking a knife and sticking in your gut and spinning it 

Naren: Right

Gary: you know now there have been some class-action suits by dentists in states against the insurance companies for this class action lawsuits; however, to my knowledge, none of them have prevailed.’

Naren: the insurance companies have prevailed 

Gary: the insurance companies have prevailed, yeah

Naren: I think they have so much money, Gary, they have billions of Dollars 

Gary: Yeah, they have so much lobbying money and influence that that’s why that happens 

Naren; yeah, I mean you take up ten guys who make billions of dollars, and you pay a bunch of consultants 10 million dollars; I’m sure you know you can get anything you want 

Gary: So, they can have experts at the trials they can have all kinds of clout that you know a dental society pales you know imagine that lawsuit and you’ve got a, a, dental society with very little backing their complaint and you’ve got the insurance company with these higher guns backing their complaint

Naren: right 

Gary:  but a client of mine, and this is the note of caution, said Gary, could I just work around that? Can I just tell the patient that well? Because it’s cosmetic, it’s not covered, and we’re not even going to bother submitting claims because it’s, it’s, not covered. Now I had to tell my client, as much as I would love to do a workaround here, do not do that, do not do that’s a violation of the contract. If you read the contract, it’ll be on page 287. Now I mean, I don’t know if it’s on 287, but it’ll be buried somewhere in the contract that says if you charge your UCR fees on fees that aren’t covered by insurance, there are serious repercussions, including the possible loss of licensure. So, my client just thought common sense couldn’t I just tell the patient, hey, it’s not covered, it’s, it’s, cosmetic it’s not covered because it’s not kind it’s not covered, we don’t even submit any claims for that. However, that’s something I told my client don’t even think of stepping over that line is if you step over that line, you make risk possible loss of licensure. Now that may sound extreme, Naren, but we simply don’t want to take any risk with doctor’s licensure because it’s, it’s, 

Naren: that’s not worth it; I mean, you go to dental school to become a dentist, and now you can’t practice; they ban you. That doesn’t make any sense.

Gary: there’s case law in this Naren; there have been some cases where doctors have routinely in contra their contract with the insurance company, and they routinely wrote off the co-payment is where patients say I’m only going to have this done if you accept what insurance pays in full, I don’t want to pay anything myself and doctor this would make no sense business-wise, but maybe the doctor was feeling desperate and said well a little bit income would be better than none, okay I’ll do it for you I’ll waive the co-pay that makes no sense right?

Naren: right 

Gary: business-wise

Naren: absolutely no sense 

Gary: no, and there have been cases where that’s been a pattern, and there have been cases of loss of licensure, then you’re in complete violation of the contract. So that’s the third nightmare now. Fortunately, we were able to avert that; in this case, I said no no, no no no, no, don’t do that, don’t do that. Do not I hear you- I understand the rationale; it makes sense to me, but that’s putting your licensure at, at, stake, and we do not want to take that risk.

Naren: it’s almost like they want you to go to dental school, get half a million dollars in loans and then come and do two dentistry and you know do what they tell you to do otherwise, you know too bad

Gary: You know, I ask a question in my live courses because this used to come up fairly frequently. Someone in the audience would raise their hand and say, hey, I used to work for delta, and this is what we found out. This is what we did. I used to work for MetLife. I used to work for a blue cross blue shield I used to work for travelers, and by the way, all of them had left because they probably didn’t like what, what, the business practices of the insurance companies, and they decided I’m going to go work for a dentist they’re the good guys. 

Naren: right 

Gary: but that came up all the time, and so I would I developed a joke that I would ask, and I’d ask the audience, hey by the way, just before I go on and share something else do any did any of you happen to work for the dental insurance companies and then oftentimes everyone would say no but I’d say, the truth is all of you if you’re in-network work for the insurance companies.

Naren: right

Gary: figuratively, not, actually enrolled 

Naren: so, they have even more control than people have over their employees 

Gary: Yeah, they do

Naren: imagine putting these conditions on your employees; they’ll say take a hike 

Gary: who, who, else has the authority to set your fees 

Naren: Yeah, it like 

Gary: does the dental society have the authority to set your fees

Naren: it’s like a dentist telling his team member, hey, I’m going to pay you half for whatever reason; yeah, this is the way it is

Gary: does the state dental association have the authority to set their fees 

Naren: no 

Gary: does the ADA have the authority to set the fees 

Naren: absolutely not 

Gary: no, it’s the only one that has it besides yourself if you’re out of network

Naren: Right

Gary: the only entity that has the authority to set your fees is the dental insurance company 

Naren: Right

Gary: by virtue of that contract, so this is just a, a, I hope you’ve enjoyed this podcast, although I hope we’ve kept your blood pressure at an appropriate level. It makes me angry. What’s the best way to how’s the best way to handle that? Take your ball, remember Naren, this used to happen on the playground when we were kids the kid that has the ball could, could control the game.

Naren: Right, got it

Gary: you know, if he took his basketball, then we couldn’t play basketball, so doctor, you need to take the ball and go play your own game, which is to be out of network because that’s what we’re fighting against. Hey Naren, and as we come to the finish line today, we actually have a resource that’s going to help all of our listeners do just that to go successfully go out of network. Let me talk about that for just a minute. Recently you and I started the very first digital dental academy. It’s called RIDA, RIDA and RIDA is, is, both plan words we want to help you get rid of the insurance; hey, I know that’s not grammatically correct, but we like the way it sounds, but it’s also an acronym. It stands for RIDA reducing insurance dependence academy. This is a group of like-minded dentists and team members all over the country that are part of a groundswell movement successfully resigning from PPO plans. I want to invite you all to come to join us; if you listen to this podcast, you’ll love to be a member of the academy. Hey, and at least for the first year, your membership fee is free. We’re waiving that that’s a gift to us. Our gift to you come to join us you can go to www.rid.academy. Come join us. Take advantage of all the free resources, and maybe one of the most important benefits of being a member of this community is you’re surrounded by like-minded people who are on a similar journey or have been on the journey and can share their wisdom with you. On that note, let me thank you all for listening to the less insurance dependence podcast; thank you for the privilege of your time. We look forward to connecting with you on the next episode.