By Nancy Dukes, RDH
Do you ever find yourself paralyzed when it comes to treatment planning because you are overwhelmed by the multifaceted nature of insurance reimbursement and just wish it were not a part of your dental practice? You are not alone. Most dental professionals have wrestled with this same dilemma at some point in their career. There are so many very different plans and restrictions, not to mention patient misunderstandings of the entire dental insurance concept.
To resolve such problems and ensure a pleasant journey toward oral health with patients, the dental team must begin to become insurance aware, not insurance driven. This can be accomplished by focusing on the goal of providing the quality, individualized care each patient needs and desires based on clinical evidence.
Focusing on evidence-based care in hygiene can greatly simplify the insurance coding challenge. This change in focus to being insurance aware begins with a comprehensive evaluation and diagnosis, and continues with a comprehensive treatment plan.
Comprehensive evaluations should include the following:
• Health history review
• Blood pressure screening
• Head and neck evaluation
• Oral cancer screening
• Full-mouth periodontal probing and evaluation
• Missing teeth
• Existing restorations
• Defective restorations
• Caries
• Radiographs
• Diagnosis and periodontal classification
• Treatment plan
By changing one's focus to what is in the best interest of the patient rather than what benefits the insurance plan will provide, the dental health-care provider can embark on a journey unobstructed by roadblocks and detours.
When it comes to periodontal disease, treatment planning and insurance coding are greatly simplified if we answer a couple of basic questions to determine the direction our journey must take:
• Is there bone loss?
• Is there bleeding?
Regardless of the dental history, if the answer to either question is yes, then the patient is in some stage of periodontal disease and requires treatment. This may be treatment for gingivitis, a curable stage or periodontitis, or a noncurable stage of disease. Regardless, both are periodontal disease, according to the latest periodontal disease classification system (since 1999), and require therapy. Patients have come to you trusting that you will make recommendations based on evidence of need. They trust that you are the experts and that you will map out a plan to keep them as healthy as possible even if this requires out-of-pocket expense above insurance benefits.
Treatment plans must be based on standard of care, not on provisions of insurance policies. As we know, insurance benefits have no relationship to what is necessary for treatment or control of disease. Benefits cannot be the sole consideration when making decisions about treatment or you betray the trust patients have placed in you as their dental care provider. Not honoring this trust is actually a disservice to the patient. This also perpetuates the patient's false understanding that the insurance carrier somehow knows and understands his or her situation.
A key to patients joining and staying on a journey to oral health is, of course, comprehensive diagnosis and treatment planning. But effective communication and patient education are critical as well. We must not only stay true to our goal of evidence-based, individualized care, but we also must help the patient understand the reasoning behind our recommended plan and complex third-party payer issues. This requires a systematic team approach to comprehensive care and patient education. Everyone must have the same itinerary and be following the same map. Once you can effectively communicate evidence-based care, patients gain an entirely new understanding of your recommendation for what is in their best interest. They are genuinely appreciative. The original trust they had in you as a dental professional is only enhanced.
The team approach to a successful patient journey requires that the dental practice have protocols in place for all types of hygiene therapy:
• Healthy adult prophylaxis
• Healthy child prophylaxis
• New-patient experience
• Esthetic maintenance
• Edentulous patient
• Implant patient
• Gingivitis therapy
• Periodontal therapy
• Periodontal maintenance
Along with these protocols, the entire team must have a comprehensive understanding of proper ADA coding. It is not adequate for only the business team to have this knowledge. Continuity of patient education is a must. This is one of the greatest challenges in today's dental practice as you make the journey from insurance driven to insurance aware.
Knowing when to file what code, when not to file different codes on the same day, what constitutes an excellent and appropriate narrative to secure reimbursement, frequency limitations, clinical evidence necessary to justify the use of a code, documentation necessary to guard against postpayment insurance audits, etc., can become a practice wreck without a systematic team approach. Just as delivery of clinical care requires specialized training, so does delivery of patient education. Dental teams must be committed to continuing education for themselves to better serve their patients.
Honoring one's goal of individualized, evidence-based care for every patient, committing to professional growth and development of the team, and following the same treatment plan map toward dental health can translate into a very pleasant journey for patients and dental professionals.
Jameson Management, Inc.'s Nancy Dukes, BA, RDH, invites you to expand your horizons in the area of patient motivation by joining in a series of articles to discover the keys that will enable you to book more passengers than ever imagined on the journey to wellness. The Journey to Hygiene Excellence will not only include this Wellness Approach to Clinical Care article, but features on comprehensive health evaluation; systemizing your data collection and documentation; treatment planning and ADA coding; building relationships of trust through effective patient education; case presentation and treatment acceptance; and building retention and referrals while offering a healthy new-patient flow. Dukes is director of clinical consulting for Jameson Management, Inc., an international dental practice-management consulting firm. Visit
