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Bureaucratic Nightmares of Dental Insurance

The last few years we have heard a lot about health care reform. Dentistry has been included with medicine as if it is the same animal. Well, Dentistry is definitely different! But more about why in another article to come about so called "Managed Care". For your 10,000 Kbytes of this article I am going to talk about my own personal reform package concerning the dental insurance industry. Hopefully, if some of these reforms were in place money, time, and frustration would be saved by all parties involved. Yes we could have a win-win situation for dentists, dental staffs, patients, and insurance companies!

Let me explain why I am on this tirade at this time. A few months ago I experienced turnover at my front desk. The person who left was a key person. While I had a second person at the desk, she was not really allowed to know and do everything by the leaving Queen of the Front Desk. This resulted in me discovering and learning what really goes on at the front desk! (As an aside--don't let the Queen of the Front Desk syndrome happen in your office--Cross train, Cross train, Cross train) Boy were my eyes opened! I am still suffering from the shock.


Not only do I have a much higher regard for what my front desk people have to deal with on a day to day basis but I also have a few ideas for insurance reform. I also want to mention the plusses of dental insurance. Dental insurance has made it easier for Americans to pay for their dental care. I think the verdict is out whether the net effect of insurance has been to make that care less expensive (at least when all costs, preminums, fees, etc. have been considered). My basic gripes about dental insurance arise from two areas. One is paperwork and number two is language.

Some Paperwork Problems

Some Language Problems

I just thought about a third trouble spot. That concerns forming groups of providers while excluding other dentists (Not giving any payment unless you go to selected providers.)


Let's review and explain the above. Contract booklets should have spelled out what exact ADA codes they cover and have a schedule of fees. Listed after the fee that they consider their scheduled 100% fee they can state at what rate they reimburse: 50%, 80%, 90% or whatever. This would eliminate all the mumbo-jumbo about UCR (they should never be allowed to use that term. That term is the most abused three words in the English insurance language). I have more patients give me grief about that term. It's just amazing how that term makes it sound like God determined the fee and if mine differs I have sinned. It's also amazing how of the 200-300 companies I deal with they all seem to have different UCR's. Also amazing is the fact they always point out to the patient any of my fees that are over their number but never pay more if my fees are under!

Predetermination is just more paperwork. It takes the insurance companies and my staff more time, delays treatment, requires my X-rays to be out of the office when sometimes the patient has an acute problem that I need the X-ray for only to find it is out at the insurance company!

Why? Why? WHY do we send in X-rays? X-rays are used for diagnosis. Diagnosis is done by the doctor and explained to the patient. The insurance company has no business looking at an X-ray. They are paying for treatment rendered. Policing for proper treatment rendered is up to the state license boards and the patients. I know every patient is anxious to have an extra unneeded root canal done. The nature of dental work and the fact that patients have to pay co-payments keeps the doctors as honest as sending in X-rays. Insurance companies only business is to reimburse for treatment rendered. They can check that what we say we have done, we have done. Have the patient in and take a look on their time not mine. If they need to see that the patient had a crown done on #19 take a look see. People that are going to defraud insurance companies will succeed if they want too. Why burden everyone with unnecessary paperwork and expense because of a few doctors that will defraud anyway.

How can anyone lose the amount of paperwork that the insurance company does? I am all computerized, the forms are very neatly typed, etc. They lose 5-10 a month. I have had them lose one of two that I sent in the same envelope. If I made that many mistakes I would be in a jail cell counting tea leaves. It delays payment and costs me postage and staff time to call and make out new forms. They never pay me for all the paperwork I do or my computerized forms. I should figure out a way to run a business and have some other business take care of a bunch of my paperwork and not charge me! I had an insurance company send back an envelope of several claims because it needed another 23 cent stamp. (We were slightly over 1 ounce) For this I had to pay twice for the postage, put it in a new envelope and wait 2 additional weeks for payment.

While we are on forms, what about requiring one of their forms once a year or with every claim. How ridiculous! If they are so in love with their form they can have a clerk in their office fill it out. The dang form is almost identical to my computer forms. It's just a total logistical nightmare for my office. The staff has to remember which companies require their forms and when. Hey! Even with my very sophisticated computer program I can't keep track of this! I have invested thousands in computers to print out the DAMN forms--they can accept them without this other S@##$%. Better yet they should all accept electronic claims (without the X-rays!). Again-- the electronic claims save me a ton because of less paperwork, staff time, postage etc. and delivery is quick and they can't say they lost the dang things. They should love it because they don't have to have people input the info on their end. That should save them a bundle! The truly interesting part is that we, the DUMB DENTISTS, pay to submit the claims electronically. The insurance company should pay us for the money it saves them! Few companies accept electronic claims. WHY? WHY? WHY? If a lowly dentist like me can buy the equipment and make it work, why can't they?


While I have our blood pressure up let's talk about coding problems. Especially frustrating are periodontal codes. Each company has a different system. When you call they tell you that you have to code this way or that to have your patients work paid by their company. Lost in the abyss is the fact that you really need to code for what you have actually done. A glaring example is in order. A patient comes in and requires a root planing you code for 4341. Note comes back from insurance company they do not pay for root planings. Your staff or patient calls the company and their clerk says that they will pay normal prophy fee but you have to resubmit. I have two problems with this.

You really shouldn't code for a different procedure than you actually did. What if that patient sues you for periodontal neglect 4 years from now? Their lawyer will note that you only did a normal prophy when they needed a root planing.

Secondly, the insurance company should automatically pay the lower fee for at least a normal prophy. We all know that when root planing is done a normal prophy is done and much more.

Another coding problem example is with various types of restorative materials. Sometimes they will not pay for one type of material and suggest they will pay for say an amalgam. If you use the other material they won't pay at all! What business is it of theirs what material you choose to use? We shouldn't have to argue about our clinical decisions with the insurance company. The contract says they pay for restorative dentistry so they should pay--not argue about materials. If the fillings don't last they can limit how often then will pay for replacement. The responsibility for longevity rests on the dentist's and his patient's shoulders--not theirs!


Last on my list of paperwork problems is orthodontic claims. I couldn't believe what goes on with this area. We submit a form when we start treatment. Fine! After this is when the ridiculous part starts. The insurance company expects us to submit forms--some every month, some quarterly, some bi-monthly. If we submit quarterly we must list each month's charge separately rather than combined into the total for the quarter. Hey, you can't mail 3 forms for the quarter--you must just give one with three codes on it. Not even my computer program can handle 5 different ways of doing this so we have to do it manually. This is utter nonsense. What is the purpose for all this? They know patients almost never disappear and stop treatment. They should set up automatic payment without resubmitting forms or at worst send us a verification form. In other words: They should do the paperwork, not us!

Well so far I have worked myself up to a massive headache. We will continue with this fun topic next month and end it with a summary. Thanks for reading. Send me e-mail if you have comments!

Robert H. Doty D.D.S.

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