Explaining Insurance Benefits To Patients

Have you ever experienced a situation where the patient wanted to know more information
about “what their insurance will pay” and you were expected to have the answer? Of
course, you have, this is dentistry! Unfortunately, with the changes in dental insurance in
the last few years, patients are becoming savvier and we are helping them. Or are we? Let’s
focus our conversation on their dental needs instead of their benefits.

Here’s how:
1. Don’t own the problem.  It’s really easy to assume your patients will only complete
treatment for which their insurance provides a benefit. Concentrate on changing your
thinking. If a patient understands and agrees with the need, they will find a way to have
that treatment done. Your clinical team should focus their conversation on why this
treatment is necessary even if it is downgraded, not covered, or excluded. As clinical
providers, it is your responsibility to present the highest standard of care without the
influence of their level of benefits. Once your clinical team has reviewed the risks of not
proceeding along with the benefits of the treatment, a commitment question should be
asked of the patient to determine their level of interest. If the patient answers that they
would like to get this treatment scheduled, that information should be handed off to the
business team in front of the patient at the checkout. When it is presented in this order, the
patient will have owned the need for treatment first and then the insurance benefit
conversation can take place. Ultimately, the business team can circle back to the need of
treatment if the patient is concerned about the benefits provided. It is not your fault if the
plan downgrades, excludes, or does not cover the treatment the patient needs.

2. Be cautious of your language! Often, I observe business team members use the word
estimate and the patient perceives it as a guarantee. For offices that are unrestricted, or out
of network, the practice management software and the available EOB’s from insurance
companies can be utilized to give us a best guess for the patient’s responsibility of the
treatment. However, when you print a treatment plan and it shows the total treatment, the
insurance write-off, the insurance payment, and the patient responsibility identified to the
cent, you are sharing what the patient perceives is an exact amount in which they will be
responsible. Depending on the benefits of the plan that may or may not be true. Try
replacing the word estimate with some of these phrases:

      “With the limited information provided by your insurance company, you
may receive some benefits from this plan.”
      “There are no guaranteed benefits but we provide as much information as
possible to the insurance company.”
      “Ultimately, you are the subscriber and the insurance company will likely
provide you with a more detailed explanation.”

3. Dental insurance is not going to get easier to explain or predict. The guidelines change
from plan to plan. There are a lot of scenarios that you will learn from as you navigate and
provide this service of filing insurance for your patients. How you explain these challenges

to your patients when you are presenting treatment will determine their acceptance of the
challenges when they occur.

Danya Montoya EDDA, CIS, CDD, is Chief Program Implementation Officer for Jameson
Management.  Her passion and proficiency with CAD/CAM dentistry helps Danya bring unique
and powerful programs to audiences nationwide.  With experience in CEREC and E4D designs
and operations as well as being a Certified Integration Specialist and a Certified Dental
Designer with Planmeca University, Danya helps the entire team understand their individual
role in making technology a partner in the practice.   With more than 22 years of experience
in the dental industry, her love for dentistry exudes through her desire to coach teams to
achieve their goals in a deeper way where others have only scratched the surface. She not only
provides in-office coaching, but works with the Jameson team in developing specific programs
for optimizing technology and systems in dental practices.