NMDA Journal Winter 2019-20

18 New Mexico Dental Journal, Winter 2020 Dentists have long been forced to make the decision of taking insurance or not when it comes to establishing their practice and building a patient pool. Over the years this has become a more and more complex issue. This has been a much- debated topic with strong arguments on both sides being presented. You can spend an entire weekend at a conference listening to gurus tell you which insurance plans to take, which to avoid, and—if you do take insurance—exactly how to bill and what codes to use to minimize your write-offs and maximize your collections. And when you turn around you can listen to all the other dentists and practice managers telling you that if you stop taking insurance you will have a more“stress-free practice”that makes more money. So here we are in the middle hearing both sides and weighing our options. Should we accept on insurance and, supposedly, gain more patients by being on their provider lists but in doing so take a fairly significant hit on our collection percentage; or do we get paid for everything that we do, maximizing our collections percentage as much as possible but possibly see less patients. As a dentist who has only heard of what things used to be like and has only practiced in what the present insurance landscape is, all I can do is offer my views on what I see to both sides. And judging on the profits of insurance com- panies these days, I don’t see insurance going away any time soon. So, this article is not aimed at presenting a clear winner, it is merely a briefing on what I have experienced thus far and attempting to point out a few consider- ations that you may or may not be aware of as a new dentist. Let’s start with the fee-for-service practice. You as the dentist show up, treat your patients, and they pay you for what you do (most of the time hopefully). From the dentist’s side, there is no worrying about what kind of write-off each procedure will carry, whether insurance will cover a given procedure, narratives and documentation to“prove”that it was a neces- sary procedure or avoiding frequency limita- tions. The simplicity also gets passed on to the patients as well since they no longer have to worry about their insurance plan dropping their dentist or their dentist dropping their insurance plan. They also don’t have to deal with the uncertainty and headache that come with insurance and patient portions, yearly maximums, and again frequency limitations (especially on things that the patient both wants and needs). Unfortunately for the patient, this practice model does usually stick themwith 100% of the bill at the end of the day; but, due to sever- al different factors, this may or may not neces- sarily mean it is more expensive for them over several years. I tell many of my patients that they should take the money that they are pay- ing on insurance premiums and stash it away, ideally in an HSA to get the tax benefit, and then have cash on hand for dental treatment. I have not personally had an entirely insurance- free practice ever, so granted this is the model that I can’t speak much to from experience. But I will admit, the simplicity of it does always seem appealing. Since the pros are fairly obvi- ous, I will elaborate on what my perspective of the cons are. The biggest one being patient population. I may be incorrect, but when I consider our state’s overall financial situation, I have a hard time imagining there is a surplus of cash-paying patients. And when I evaluate our own practice, which has an extremely wide range of patients from all different walks of life, I see that there is a significant number of patients that get their insurance through their employer. For these patients that get their premiums already paid for, or significantly dis- counted, it only makes sense for them to take the benefit of having the insurance. And think this is true for a majority of our state’s popula- tion, so if you stop taking insurance it could significantly limit the patient pool that you are drawing from. Another consideration if you are strictly fee-for-service is that you may need to spend more on marketing your practice. Since patients are no longer getting your name from their list of providers per their insurance, the onus will be solely on your marketing plan and your patient’s word-of-mouth. Now let’s move on to accepting insurance. In short, you should gain more patients by ac- cepting more insurances. In doing so, you will have to accept (after as much negotiating as possible) a fee schedule for your services that is probably going to be about 60–80% of your practice’s normal fee. If it stopped here, it Considerations in Accepting Insurance By Joe Gherardi, DDS could be a fairly straight-forward calculation to estimate whether your practice (given its geo- graphic location, socioeconomic surroundings, and mission and vision of the practice) would be better suited to accept or not to accept insurance. But this is where it gets way more complicated. Because the more insurance companies you take the more you open your- self up to merging with other plans and taking lower and lower fee schedules without di- rectly knowing it. I will only briefly explain this “umbrella”phenomenon. Basically, insurance companies can partner with each other and sell their list of providers to other insurances so that you may end up on certain insurance provider lists with their attached fee schedules that you never directly agreed to. For instance, you currently accept insurance company A and their (good) fee schedule and later decide to accept insurance company B and their (lower) fee schedule. If company B has an umbrella agreement with company A that you didn’t know about and now you are a provider for company B, insurance com- pany A may now be able to apply company B’s fee schedule to all of their patients, even though these patients carry insurance A—not B. Many times, these umbrellas are more like 3 or 4-sided Venn diagrams with companies overlapping multiple times. It is very confusing and this is a very crude explanation of it, but just know this, when it comes to multiple fee schedules for the same insurance company, unless you and your office are actively engag- ing and negotiating these insurance agree- ments, the insurance company is going to find a way to take the lesser of the fee schedule. So, if you do accept insurances make sure that you or your office manager has an understanding of this. This is where a collaborative dental group or dental service organization can really come in handy in being able to use a large number of dentists and providers to not only be able to negotiate better fee schedules but more importantly to have somebody desig- nated to monitor these insurance contracts and make sure that you are coming out“on top” of the umbrella and not on the bottom. In the end, there is always room for both types of practice in most locations that you may practice. You, as the dentist, really have to decide what type of practice you want. Both can be very profitable and both could end up