Insurance Saga 2026

It has been a while since Bethany and Dr. Kuba have tackled the ugly topic of insurance. They jump right into tough topics in their first 2026 episode together! Insurance ranks at the top of their list. After a recent incident with a parent who was frustrated about insurance coverage (or lack, thereof), the situation was brought to Dr. Kuba’s attention and ultimately to Bethany’s attention as well. It reopened dialogue regarding the shenanigans of dental insurance. Listen in to this refreshed conversation! 

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Transcript

Are you looking for a podcast where you can hear from real people regarding their real dental drama? If so, then

0:09

you've come to the right place. Join hosts Bethany Penny and Dr. Reena Kuba

0:14

as we dive into the solutions we've created and the mistakes we've made

0:19

while managing dental drama. Let's get started. Do you know what today is?

0:25

What? It's our first podcast of the year together. I know. This is ridiculous.

0:31

Hey, we've we've had some things going on. Yeah. Well, your goats first of all, that was

0:36

one deterrent. That was a big deterrent. Still is a deter deterrent, by the way.

0:42

Yes. Um and then uh we both kind of couldn't really talk.

0:47

Yeah. I think this is Yeah, this is the first day I'm feeling pretty good with talking. I know you're still packing up

0:55

all kinds of fun stuff. Yeah. Yeah. and you're trapped in this car with me right now. Um, so anyway,

1:00

I'm excited. Like, we haven't seen each other in a bit and like sitting here trying to catch up and go, what do we want to talk about? What kind of drama

1:07

is going on in each of our worlds? Oh, yeah. So, I'm going to tee us off here with one that's um yucky and not new. And

1:17

yet, I still find myself we're still struggling with this. Um, so you kind of

1:22

have a taste because I messaged you two days ago.

1:28

Um, but I wanted to talk about it because we we've just texted each other and um, and I I would I I doubt it's

1:36

just me going through this. So Oh, it is not just you. No. Um, back to insurance, our favorite

1:43

topic. Um, God. So, I I'm assuming and

1:48

thinking this is going to be universal whether you take insurance and DHMOs and

1:53

Medicaid or whether you're out of network. Like, I feel like the situation you're going to get hit with regardless.

1:59

Agreed. And uh I think for me, I don't know. Um

2:06

it it was brought to my attention, which means God only knows how many times that this is. So, if you're an owner and

2:12

you're like, "No, we don't deal with that." I doubt it. Go ask your front desk. Go ask your people.

2:18

Yeah, unberry your head and then go find out. Um because that's what we tend to do, especially with this topic.

2:24

Um so I'm trying to think of the best way to tee this up. I think what I may do is go back to the message I sent you.

2:31

Okay. Um cuz I sent you a series of like 10 screenshots. I was like, "Hey, by the

2:36

way, I'm about to bombard your um phone here, so give me one sec. Let me find

2:42

it." And then but yeah, so it's it's nothing that um

2:47

that is unique or new. Yeah. But I'm still going okay are are we

2:52

doing anything different? Is the landscape different? So some of mine has been you know this

2:59

last year we have been out of network with most insuranceances. So this last year is where we were really kind of

3:05

watching carefully to see who came back in 6 months, who declined to come back,

3:10

how many people were like, "Okay, yeah, my out of network uh portion wasn't bad, so I can keep going where I want to go."

3:17

How many people came back once, but then now they're like, "You know what? I don't I really don't want to pay that." So is that

3:24

are we out of the woods yet? Is this our new normal? Is it because the economy

3:30

and we're going to war with everybody and their dog? Maybe we are, maybe we're not. I don't like So Manny talked a lot

3:36

about that on his episode uh recently. Just uncertainty. Uncertainty. So I just don't know. Um

3:45

but it it is hard to then project what we need to be doing. Yeah. Do I need to get back in with network?

3:52

Do I need to what do I need to do? I need to be writing off everything right and left like what what am I doing?

3:59

And um so again not new but just a reminder of going what am I doing?

4:04

So okay so I got uh a message this was on um two days ago

4:12

and my um one of my team members was like did anybody mention I'm going to

4:18

call her Miss Smith. Did anybody mention Miss Smith to you? because I'd popped into the office

4:24

briefly and then I left and they're like, "Oh," my manager was like, "When you were there, did anybody mention Miss

4:29

Smith to you?" I said, "No, I was barely there. I ran in, ran out." Right? Burying my head in the sand. Didn't want to deal with anything. Hey guys, I'm

4:35

here just to drop this stuff off. Bye. See you. And that's what I did. And she said, "Well,

4:40

uh, so I'm just reading the text message here." I said, "No." Um, so she said, "Miss Smith has an $800 balance. She

4:46

went to another dental office in the summer, but didn't tell us. So, her December appointment for her three kids

4:52

was denied and she's throwing a fit. So, my response to that, again, this is via

4:58

text, was um not really our problem. Uh to which my manager replied, "Haha." And

5:04

then I said, "Is she saying we didn't check benefits, therefore it's our fault." Is that where this

5:10

conversation's going? Um so, uh manager says, "Yep." and she

5:16

goes, "I'm going to hear her out and see if we can do a payment plan."

5:21

Um, so the mom is saying, this is again his manager. Mom is saying, "We should have

5:26

looked up that they had been seen, but we didn't check that." Um, so it's our fault.

5:34

And my manager is like, her argument to the mom is like, "But why would we think we you've seen us every six months for

5:41

the last three or four years. Why would we assume you've gone somewhere else?" Exactly.

5:46

Um, so then I asked, "Did our billing people,

5:53

did insurance show they'd cover it or did we not check it or what what happened on our end?" And my manager

5:59

said, "Well, if it's been over a year, we check it, but not if it's just been 6 months cuz we're assuming, especially if

6:05

you've been coming every 6 months." So, first of all, I'm going to interrupt myself here and go, I don't even know

6:11

what our protocols are, right? This is kind of a reminder to me to go, I don't even know what we're doing anymore. What are we verifying? We

6:17

verifying anything? Are we verifying nothing? Who are we verifying for? So,

6:23

and I say that to say, are we part of the problem in that? Have we given this woman the impression that we do check

6:29

that? So, is this an US problem? And should I write off the 800 because it's an US

6:35

problem? But at this point, I'm not convinced of that. So, I have to now do a deep dive into

6:40

what are our systems. And I'll be honest, 2 days later, I've still not done that. Like I'm thinking about that

6:46

right now and going I don't want to do that. Um so anyway, let's table that for a

6:53

minute, but that's just like my thought. Pin that again. Yeah. Head bearing again. Um,

6:59

so, so my manager said she if they were just seen in April, she wasn't going to check

7:07

their eligibility for December because we're going to assume if in April we saw that they had two cleanings a year,

7:13

they've only had one, we're not going to check it in December because they have been coming to us every 6 months. How are we to know that this mom took them

7:20

somewhere else? And apparently she took them somewhere else in July, which then doesn't make any sense either. if you just had cleanings in April, why would

7:26

you back? So, yeah. Anyway, um so my manager says um that she checks

7:33

if they're active. Um and then I guess

7:38

this woman was talking about how we didn't check a portal and we have an outdated portal and it's not her fault

7:44

that we didn't check it right. And I'm just like, okay, I I I don't I don't know what to say about all this. So my

7:50

response was, um, yeah, we just tell her we check if insurance is active or not.

7:55

Yeah. And it was active. And I guess they did pay for some x-rays or something. So to me, I'm like, that's what we hang on to

8:01

then is going, well, insurance did pay some. Yeah. So clearly you did have some benefits. I

8:09

I don't know. Um, and then I said, we don't need to get into the details of why she went somewhere else.

8:16

um I just say that verify was active and she needs to talk to to insurance about

8:22

why it was um denied like we can't control her insurance.

8:27

Um so apparently then manager replies back and she says she went back and forth with our billing person and then

8:32

at that point she was like mom was flip-flopping and going no no no we didn't go somewhere else. I just took

8:37

the one kid somewhere else cuz she chipped her tooth. But then it's like but then why would insurance deny all

8:43

three? So, I'm just like, anyway, um, sorry, I'm going through these texts,

8:49

blah blah blah blah. Uh, so finally my manager says, I'm going to just hear her out and try to get her on payments or we

8:56

can write it off, but we won't be able to see you if the balance until the balance has been paid. My problem with

9:03

that is legally I don't know that we can do that, correct? Because then that counts as patient abandonment and whatever. So, um,

9:12

so I was like, I mean, writing off the $800, like that's exceedingly generous,

9:18

but whatever. Um, so

9:23

then she I guess the mom said she would pay $300. So now mom is

9:28

negotiating, negotiating, and trying to decide, which to me indicates, you know, this is a you problem.

9:34

Yeah. You went somewhere else. You didn't tell us. Now you're back in December and now

9:39

you're going, "Oh, this may not be covered." Well, let's see what the dental office says.

9:44

Yeah. And so I guess when my manager eventually did call her, the mom was like, "Well, that's why I asked I asked

9:50

when I called and I asked the front desk and I asked like, "Am I going to owe anything?" And everybody said no. So

9:58

that's y'all's fault for telling me no. Yeah. So then it it goes back to is she right?

10:06

Like is that an US problem? What where do I oh do I do I lose this

10:13

family of three kids at a time where the economy is bad and whatever, but then if

10:18

I write it off, am I setting up expectations

10:23

expectation that you just need to be a squeaky wheel? Yeah. And just throw a good fit and

10:29

Right. But putting that aside, are we culpable in this in that how much do we

10:34

check for each patient and what should we be checking and what should we not? So I don't know that's where I said to

10:40

you like what what am I doing with this? Um,

10:46

and then, um, blah blah blah blah. And then something about she was throwing in

10:51

about how her daughter is having some surgery, so she's strapped for cash. Which I'm like, okay. Again, that shows

10:56

that, you know, it's your fault. Like, yeah. Are you going to go to Kroger and say,

11:03

"Well, I want to buy the grapes for three bucks cuz Walmart's selling them for three." I guess that's where she was

11:08

like, "Well, why are your fees so high? Like other offices, I would have paid 100 bucks a kid." So that's what I'm

11:14

going to pay you. Oh, so now we're price matching. Is that what we're doing? Like I don't know. And what office out there is actually

11:19

100 bucks a kid? Like that's right. So then I was like, honestly, I

11:25

don't think we're writing off anything. The best I can offer you is payment plans. Like pay it out over four payments. Like normally we don't do

11:30

that, but that's fine. You've been patients for a while. Take your time to pay this out. That's fine. Um to which the billing person then was

11:36

like, "Why can't she apply for Care Credit?" I'm like, "Yeah, why can't you? Why am I having to solve your problem

11:42

here?" Yeah, you took the services. Yeah. Um then my manager says, "Well, I'm

11:48

going to reduce it." So, whatever she said of why she's reducing it. So, then I was like, "Why?

11:55

Why are we reducing it? It makes it look like we did something wrong and she's squeaky wheel has a tantrum. So, now

12:00

we're going to cave." Well, then she said, um, the manager said, "Well,

12:06

usually if fluoride's denied, like what we our office fee is, let's say 50

12:11

bucks, but if it gets denied, usually we drop it down to like 29." Yeah. We have like an office special or

12:17

something. Yeah. And I went back to, okay, again, why? Yeah, but whatever. If that's what we normally do, but I'm like, okay, the problem here

12:24

is if we sent her a bill that had it for 50 Yeah. And now you say, "Fine, I'll drop

12:31

that to 29." Then still it opens a can of worms. It opens a can of worms. Like you just had to squeak. So now you're going to

12:37

go, "Okay, well what else can you do for me for the exam fee and the cleaning fee? You're going to drop the fluoride fee. What else are we dropping?" So

12:43

point of all of this is we have to be consistent and logical. Yeah.

12:50

About why we're discounting other than it's just you feel bad that the mom has her kids surgery and you feel bad that

12:58

whatever. So my question was why didn't we send her a bill with the lower amount,

13:04

right? To which billing person goes, well I forgot. Yeah. Okay. So is that what you want me to go

13:10

to this mom with? Well, our billing person forgot that we normally discount this. Yeah.

13:16

If I was a patient, I'd be like, "That's shady." Yeah. Absolutely. So, my response was, "We can't discount

13:24

anything. The discount is the insurance." Yeah. And your insurance isn't covering it,

13:29

and that's not really my fault. So, you do owe this amount, and the best I can offer you is paying this out,

13:35

right? To which I was like, "Table this for now. just leave it alone cuz this mom

13:42

probably got the bill from us and now she's like losing her mind because she knows she made a mistake.

13:48

Yeah. By taking her kids somewhere else. She's trying to blame shift and put it on us that we should have caught that.

13:54

Yeah. Um so I would say do nothing for now and then wait till the next time when she

14:00

hasn't paid it still. Then billing person you send her the statement again and let her and maybe by then it's sunk

14:06

in that we are not you squeaked your wheel. We are not caving. Yeah. And then you've got a decision to make.

14:12

Either you are making a board complaint, you're complaining to on Google, you're

14:18

doing whatever, then we take it from there. Yeah. Or you're never going to come back to our office. Like one of those things is

14:24

going to happen. Yeah. So anyway, I'm just babbling away here. I think the point is like I guess to me

14:30

it struck out as this can't be the only incident like this. We probably deal with this every single day and I'm unaware. But I think where it came to

14:37

me, where it was where my manager was trying to warn me about it is the mom kept saying, "Well, I want to talk to Kuba. I want to talk to Kuba." Yeah.

14:44

Something about, "Well, she knows me. I want to talk to her." I'm just like, "Really? If you know me, you're going to get up in my face and tell me why my

14:50

services aren't owed? Like, you going to try to take advantage of a friend? Is that is that what we're doing now?" So,

14:56

I think that's why she was involving me, but I'm like, "How many of these are going on?" Yeah.

15:01

That I don't know. So, anyway, what are your thoughts on all of this? And yeah, the to me it's a perfect time to

15:08

to bring ourselves back into this discussion because we've got to I I would say there's a pre a message that

15:15

I've been preaching probably for a couple years now, but it's timely for this exact scenario, which is we've got

15:23

to quit inserting ourselves as the middleman between insurance and the

15:31

office. parents have expected that of us. Well, you should know. You're the

15:37

one that knows about my insurance. You You said you checked my insurance. You

15:42

said this. And it is 90% of the time it gets us into hot water. And I don't know

15:49

why we keep reinforcing that narrative. And we do.

15:55

We do it subtly. It's not quite as overt now. Like, oh, I've checked all of this.

16:00

I've talked to your insurance and this is what they're going to pay. We we've I feel like we've softened in that we we

16:06

aren't quite as bold in that statement. But we still subtly say the same message. Something like um you know a

16:14

parent calls in to schedule and they're like maybe what this mom said, you know, oh and will that be covered by

16:20

insurance? Oh, it does look like that we've uh heard from your insurance and it's showing that you're active. So

16:26

yeah, that should be covered. We don't know that. We never know that. We can never say

16:33

with certainty that insurance is going to cover anything. So why are we saying that? An appropriate response to that

16:40

would be, "Hey, I did check with your insurance. They're showing that you have active coverage." Now, whether that

16:45

means they'll pay for something or not, that's the million-dollar question that we can never seem to answer. If you want

16:50

to know for certain, I would definitely encourage you to contact your insurance company. We've got to push that

16:56

conversation back on to the patient or the parent and we don't because we want

17:02

the quick easy answer of yeah sure it should be covered. You know you get twice a year cleanings but this is a

17:09

perfect example of a patient that was consistent in our practice. There's no reason we would have thought that she

17:15

went elsewhere. We didn't do a quote unquote full breakdown where we got all the history.

17:23

And I I can hear I can hear people right now responding to me, our listeners

17:29

saying, "Well, then that's what we should do. We should get a full breakdown. We should we should log into

17:35

the portal and see the history and cross that off the plate." This wouldn't have happened if we would have done that.

17:42

How much time would be spent verifying all of that history just to find the

17:50

needle in a hay stack this lady that they actually did go somewhere else and we we were unaware of that. That is not

17:58

an efficient use of somebody's time. And I have seen people take verification to

18:04

the 110th degree, doing everything in their power to get

18:09

every piece of information and insurance still doesn't follow through and pay

18:14

something. I have seen offices that predde everything, including cleanings.

18:19

They're like, "We don't know. We're just going to pre-d it and then that way we at least have the information." Insurance itself says on that pre-de

18:26

that this is not a guarantee of payment. And I have seen somebody with a PD in hand where insurance did not actually

18:33

pay what they said they were going to pay on that PD. There are no, we cannot commit ourselves or commit insurance to

18:40

pay anything. And we've got to verbally keep moving into that gray and

18:46

distancing ourself from any kind of guarantee that insurance is going to pay. And I think if we would have

18:53

approached it this way with the mom, would it have solved it? No. She'd probably still be calling saying, "Well,

18:59

y'all should have known this, but didn't we tell you on the phone that you were supposed to check with your insurance?" "Yes, but you've always checked. I just

19:06

thought you would check." We might still be having an argument with this mom. But if we were certain that everybody on

19:11

that team was like, "I don't know. I don't know. Maybe they pay, maybe they don't." And that was our narrative

19:17

consistently, then we would call out baloney on this mom and be like, "We know we didn't tell you that." But

19:24

because we're not certain about that now, we feel a little bit of culpability in it, which I I mean, I know we never say and

19:30

our verbiage on our paperwork is also like we we don't know what your insurance is going to pay, but I think

19:36

um I think it's what a parent wants to hear. Yeah. And I do think like so this mom, I guess

19:43

she I don't know if she went back to the dental office. So apparently she was seen in our offices in in our office in

19:48

April. July she was back in her hometown somewhere else in Texas. kid must have

19:54

fallen and chipped their tooth. So, she took all the kids. And then somebody there must have said, "Oh, do you want the kids to have a cleaning?" And she's

20:00

like, "Sure." And so, I guess I think she either called insurance or called that office.

20:08

And they said, "Well, this dental office could have easily pulled up the portal and seen the history." Uhhuh.

20:13

So, that is if it was the other dental office, they're like, "Well, we could see this. Why couldn't they see that?"

20:20

So, it's other dental offices that are were ruining it for each other because and I think that's the thing where

20:25

I know it goes through my mind. I'm like, "Okay, fine. If I take the stance and then now you're not scheduling and

20:31

you go somewhere else where maybe they're making you feel like they're going to check it for you and maybe they

20:37

do check it for you and call you back and tell you it's not covered and then now you've lost that appointment." Like, I don't know. It's like how much and to

20:44

do all that work in the chance that you may or may not show up. Yeah. Um, so I I think that's the fear

20:51

is that if I'm sitting here going, I have no idea. Well, can't you look it up for me? No, I'm not going to look it up for you. You mean I got to call

20:58

insurance myself? Yeah, you got to call insurance stuff. Well, I'm just going to go down to your competitor because there's five around you in a, you know,

21:04

two mile radius. Okay. Is that what I'm supposed to do? Yeah. Um, or if I say the other fear that I

21:10

have is or if you call your insurance company, insurance is going to be, at least in my boat, maybe not for other people, but insurance is gonna be like,

21:16

why are you going to that office anyway? They're out of network, right? You should go to this person. So, now I'm encouraging you to call your

21:22

insurance company for them to tell you not to come to me. Yeah. So, is it not better for me to go ahead

21:28

and look myself and at least try to weed through some of those and have to write off a little bit? I don't know. I

21:34

Yeah. Well, and to me, it's it's you're exactly right to point out that we're

21:41

sinking each other's ships on this because everybody's different. Everybody's taken the the changes that

21:47

have occurred with insurance over the last several years in dental and they've attacked it in different ways. Some are

21:53

like, "Hey, I'm going to dedicate an entire person to nothing but verification or I'm going to hire this

22:00

really expensive company that I've outsourced all of my verification to, and they're going to be the ones crossing every tea and dotting every

22:07

every eye. And yes, that's not hiring an additional team member to do this, but I'm paying 23 $4,000 a month for this

22:15

service. So, it's basically like having an additional person. And so, some people are like, "Okay, great. I'm going to just take this as granular as I can

22:23

and make sure that we've covered all of our bases." But then we still have the human factor. We still have the human

22:29

factor of all that depth that we just put into that verification. Does dad still have that same job or did did he

22:37

get released from it yesterday? Which it happens. I've been in offices where it's like, yeah, everything's hunky dory. We

22:44

did all this verification and then they get a claim back and lo and behold, dad was actually not employed with that

22:50

business, but that had not been updated yet to insurance. And now insurance even paid the claim.

22:58

but then they want it back and they come back and go, "Whoopsie, we didn't realize that he had actually termed and we need that money back." And

23:05

so even if we take it so granular or some offices out there have taken it so granular, it still is not a guarantee.

23:14

And and we do that to try to remove all the question marks. We want to be

23:20

accurate. Accuracy is the goal. You cannot be accurate with insurance. I I just want to release you from that. You

23:26

cannot be accurate. And if we present ourselves as being accurate to

23:33

patients or to parents, then we are tying ourselves our our success of

23:40

accuracy is dependent upon an insurance company. And I don't know about you, but the last thing I want to hitch my wagon

23:46

to are insurance companies. And so, yes, there may be offices out there that are

23:53

doing it that way, but I think as a whole, collectively, my advice to every

23:58

single dental office, and I don't even know you, would be release yourself from

24:05

that identity connection with insurance. If I've learned one thing about insurance, they're shady as all get out.

24:12

They are not out for the best interest of the patient. They are unethical as

24:17

unethical gets. I am appalled at what I see them deny on

24:25

patient care. The last thing we want to do is hitch ourselves to them. So I think I'm thinking about a colleague

24:31

that reached out once and um and and I think her like spouse was the manager

24:37

and um so she the this manager spouse said something like well um you know I

24:44

don't want I I don't like when I am um

24:50

deceived like in an office. So I never want that to happen here. I don't want a patient to come in here. So, she was very adamant that, you know, for her

24:57

husband's practice, she did not want um a patient coming in and not knowing.

25:03

Yeah. And I was like, well, I I see that, but how are you controlling that,

25:08

right? I mean, the only way you can control that is if you don't take insurance and you've got your cash fee and you're saying, this is our fee and I'm going to

25:14

stick to this. Yeah. Um, so I think that was, you know, part of I

25:21

I can't even remember the question there was, but it was something about like what, you know, so we I mean like the point is we all want transparency, too,

25:28

and yet we we have no way of getting it. Um, and everything you're saying I agree with in theory and on paper and I think

25:35

we all would. I think the challenge boils down to though, but every day, how are we how are we executing that?

25:42

Because it does take a certain verbiage. Mhm. And I don't want to um I'm not the one

25:49

answering those phones. And so now here's my front desk person who's answering these phones and who is stuck

25:55

who is stuck. Yeah. Like trying to please this patient, not get their asht chewed out by this

26:01

patient and they probably have a patient in front of them. Yeah. And then they're like, well, Kuba's expectation is we need new patients and

26:06

we Right. So like it's a tight rope. Now the I never did. We had our receptionist

26:14

who was fantastic on the phone. She sent us an email with a phone call. Um saying, "Hey, I don't know how I

26:20

could have done this better." And to me, I was like, "Dude, if you are struggling, I didn't listen to the call. I'll be honest. I don't like I know I know you

26:27

did and I saw your reply to I don't know. Was that an insurance thing, too?" No. Okay. It wasn't. It was uh just scheduling

26:34

appointments is really Yeah. But

26:39

but it's a good example of even our skilled awesome receptionist. She's so

26:46

good on the phone. I don't know that you'd find many people better than her quite honestly. And even she has these

26:53

challenging phone calls. Maybe this one wasn't about insurance, but throw this one phone call that's schedule related

26:59

in the midst of all the other phone calls that she takes and those insurance calls can become overwhelming or feel

27:06

overwhelming when the parent is wanting to nail you down for how much something is going to cost. What is the only thing

27:14

that is factual in the equation? And that is the worst case scenario, right?

27:19

Like I I can't confidently ever tell you what insurance is going to pay or not

27:25

pay, but what I can tell you is this is what we have slated for the appointment. And so long as there's not anything else

27:32

added, which I don't know, that's going to be a decision between you and the doctor if something's added to this,

27:37

which that too. Yeah. Like I don't want them having those conversations, right? And then now I'm getting stuck and it's

27:42

now like I'm the bad guy because I wanted this X-ray and now the parents like are you the shady one trying to me?

27:48

Can you imagine that phone call? Yeah. Um, yeah, it's it is a tightroppe. It's a

27:54

rock and a hard place situation because we want to provide as much accurate information, but we also want to set

28:00

expectations that we can't guarantee anything. And and let's be honest, like if we think about this little little

28:09

situation, this dental situation, you compare that to medical.

28:15

And I'm always saying we would never demand the same of medical. Our our

28:21

child had a hospital stay recently and I did all the homework to be like, "What

28:27

in the crap is this going to cost us?" Cuz every year we we take a really expensive vacation to Children's

28:32

Hospital, multiple sometimes. And so I every year I'm like, "Oh crap, what

28:39

are we going to be in the hole for on this one? Let's add that to our lifelong payment plan with Children's Medical,

28:44

which I love them, by the way, actually, even though I I should love them. I pay a lot of money to them. I should feel

28:50

really good about that. Um, and so even me knowing insurance and looking

28:56

at, okay, we had a policy change this year. Let me see what this new policy is. What's our new out-ofpocket maximum?

29:03

What's our individual maximum? What's Lizzie going to cost us with this? You know, what's her maximum? Even knowing

29:10

all of that, I made my best guess on what I thought this hospital stay was going to cost us. And I was still

29:17

surprised when we just got the bill and Manny was like, "What were you expecting, you know, for the hospital

29:23

stay?" And I was like, "I was thinking it was going to be right around $3500, $4,000." And he was like, "It's 5,800."

29:28

And I was like, "$ 5,800? Where in the heck did that come from?" And I was like, "Wait a second. What's our total

29:34

out-of- pocket max for Lissy?" And he was like, "Well, it's we owe 5,800, but

29:40

it's showing that we only used 3,400 of Lizz's out-ofpocket max." And I was

29:46

like, "Well, that doesn't compute mathematically." All that to say,

29:52

we can't predict anything. And you know what we're going to end up paying Children's Medical? We're going to pay

29:57

$5,800. Does it make sense? Can I compute it? Can Nope.

30:04

Nope. I can't. and I'm still going to pay that bill. The medical field somehow mastered this.

30:10

Well, the So, I think they've mastered it because people view that as necessary. She needed to be

30:17

hospitalized. So, a parent is going to go, "Well, that sucks that I owe this money, but my kid, they never view

30:24

dental as this was necessary." Right? So, that's the problem we're in right there, which is why it it it's never

30:30

going to equate or compute. And then and yet they're willing to overlook the inconsistencies of insurance with

30:38

medical. The inconsistencies are there 100%. It's the same game that we're

30:43

playing. They justify it differently. So I think that's what we've got to keep in

30:48

mind is like not even the medical professionals can get this accuracy on on insurance.

30:57

And yet a parent is willing to be like, "Oh, well crap. that's more expensive than I thought it was going to be.

31:05

It's the same inconsistencies that exist with dental. And so, we've got to be able to correlate that and go, as you

31:12

know, I know you've probably seen this with your medical insurance, too. There's terrible inconsistencies there.

31:17

And man, I wish we could nail them down. So, I So, then that leads me to So, as

31:22

we were talking about all of this this Miss Smith and what are we doing about her? And so, you know, that was two days

31:28

ago. And then yesterday I was in the office and my manager's like, "Okay, if she shows up, this is our game plan."

31:34

I'm like, "All right, I I'm telling you, she's not going to show up. She just spent her day squeaking cuz now it's at

31:39

the forefront of her mind and she's now going to need a couple of days to decompress." So, she's I mean, like, the

31:44

thought of her coming in to talk to me, like, I think she would probably too see that that's absurd. Like, basically,

31:50

you're telling me that I'm not worth the services or whatever, or you're going to tell me that my team sucks because we

31:56

didn't tell you, right? Like, whatever. Anyway, she didn't show up, but while we were at it and we were in this vein, she

32:02

says, "You know, I this is happening frequently where she goes, I think." And

32:09

so our our billing person who kind of verifies insurance and kind of lets it leaves us some breadcrumbs of what this

32:14

parent's going to owe. I guess she was like, "Well, I'm just frustrated because the front, if it's, you know, Mrs. Jones

32:21

calls and Miss Jones is like, "Well, what am I going to owe? Am I going to owe something?" The front is saying, "We

32:27

will look into that for you. We'll let you know." And billing person's like, "I don't like that because then that's back to again.

32:34

It's on me to find the time to verify it." And then you're back to again at what how deep down the rabbit hole are

32:42

we going? Am I verifying just that you're active? Am I verifying that? Like, and I was like, "Yeah, I don't want to

32:47

get into that either." Now, I see it from the front's point. They're trying to get off the phone. They're trying to capture the appointment and keep the

32:54

appointment. Yeah. But ultimately what's ending up happening is, you know, either these

32:59

parents um either they they come and then they're upset

33:05

Yeah. when they find out that we're out of network. Mhm. Which somebody should have told them that on the phone, which again, we've

33:10

talked about why we don't use that verbiage because just cuz you're out of network doesn't mean that it's not going to be somewhat covered and blah blah

33:17

blah. Again, back down that whole trail. Um, so I was like, well, what to me it's

33:24

I get I can empathize with the front, but I I do not want you're passing along

33:29

the problem. You're kicking the can down and it's still going to blow up on us. So, we need to reconvene with our front

33:35

and frankly, we've got a lot of assistants now who want to pick up more hours and so they stay later, they come

33:40

in on days that are closed and they answer the phones. I was like, everybody needs to know about this. So then I sent

33:47

you a message yesterday and I said when the parent asks is this going to be covered and then the front leaves a note

33:53

that says the parent wants a call back to know what is and isn't covered. I am not okay with this because it puts the

33:58

onus back on us. I get that the front is trying to capture the appointment but it's really just passing the problem along. My suggestion we text them back

34:06

later that day. We text this parent back and say good news your insurance is active.

34:12

Um, but please call your insurance company to get the details of what they will and will not cover.

34:18

Yeah. So again, is that still going to leave it gray because

34:24

the parent is like, "But you said it was active." And you know, and and nobody's going to call their insurance company.

34:30

Let's be honest. You know, you're going to have somebody like me who knows that this is like my kids their well checks,

34:36

their birthdays are in April and June. Their well checks are in November

34:41

because you know one year from June we were on vacates. We ended up seeing

34:46

doing both of their well checks together in August and then the next year and then it was something about well like your insurance won't pay for a well

34:52

check but once every year. So this year when I called because they both needed

34:58

um physicals, but I don't want to pay for the physical because the physical will be part of the well check if I

35:03

could. Yeah. So, but they told me they said, "Well, you need to call your insurance to figure out whether the year is a

35:10

calendar year or a year from whatever." And I was like, "Okay." So, I called my insurance.

35:15

Yeah. But how many parents are actually going to call insurance? And then you're back to again what I said a few minutes ago. Some of these parents are going to call

35:21

and the insurance is going to be like, "Why are you going to somebody out of network anyway?" So, do I really want you calling your insurance? I really kind of don't.

35:27

Yeah. But um so then you replied back and you said um what you've been saying here

35:33

that um we've got to shift out of the let me check and get back to you verbiage because it indicates that we

35:38

can find out specifically which we cannot. So we need to switch on the call and say something like we can certainly

35:44

verify that your insurance is active as far as the specifics of what they're going to cover. Insurance is stingy with

35:49

that information. We can't tell you. So I and I'm So I was like, "Okay, I'm going to have a quick pow-wow with my

35:54

team at the end of the day." And I can already tell they're going to be like, "What the hell kind of answer is that?" Like the parent is still not going to

36:01

let you get off the phone. I said, "I am telling you, I could change my mind on this as the year goes on, but as of

36:07

right now, I would rather that parent not schedule." Yeah. I'd rather That's fine. Lose the

36:12

appointment. Yeah. But I don't want you coming in and then you being mad and then or we deal

36:18

with another miss situation where we're writing off like that. That did nobody any good here or there. I said I might

36:26

change my mind as the year goes on and let's see how dire things become. Yeah. But for right now, knock on wood, I'm

36:32

paying my bills. We're okay. I'd rather not waste everybody's time. Yeah.

36:37

And it's a decision I've I've had to come to terms with. And I knew that was going to be part of it by going out of

36:43

network. Yeah. Is it still worth it? Yeah. So far, what we're seeing is still worth it. We're

36:48

still even with like if we saw 20 patients in January last year and

36:54

now we're only going to see 11 and I'm going to still make the same amount of money, that's fine. Yeah.

37:00

Now, if I end up only seeing three and that becomes a trend, then maybe we're going to re re

37:05

figure out our strategy. But right now, if the fear if your fear is, I've got to capture this parent, so I've got to kind

37:12

of make them happy to get off the phone. I'm okay with you not capturing that parent. I'm okay with you boldly saying,

37:17

"Oh, ma'am, I will never know what your insurance is going to cover." And say, you know, we

37:23

if you want to look into that, do you want to keep your appointment or not? That's fine. Let them fall off. Or do we need to go to something like

37:29

verbiage of, well, worst case scenario, our cash fees could kick in and this is what that's going to be. Yeah.

37:35

Is this where we finally go back to a membership plan? Because we've talked about it every year and every year we I

37:41

put up roadblocks and you have tried to talk to me about doing a membership plan. Maybe that's part of the verbiage we use now and like you know what if

37:47

your insurance doesn't cover we'll kick you into our membership plan and then the most you're going to pay is this. The problem is going to be, and what

37:53

we're finding is a lot of these parents when they're coming, even if it's just like a $30 co-pay,

38:00

they're like, "No, but I want to pay zero." And if I go to somebody in network, I can pay zero.

38:05

Yeah. Which is it's a common misconception among patients and parents. They still associate that in

38:12

network equals zero. Yeah. And that is a that is a misconception that is going away

38:17

completely due to insurance changes first and foremost where those deductibles are applying to PAS or those

38:25

deductibles are applying to preventative period. Um or they're changing their

38:31

frequency so that something that was covered before is now not covered. So insurance changes first and for foremost

38:38

but second of all in network the offices that are truly still like 100% in

38:44

network they it has reached a point and it's been reaching a point where they

38:49

are having to find things to add to that appointment to be able to collect a co-ay because number one insurance is

38:56

still unpredictable with paying even for preventative and then number two they had still still insuranceances have not

39:05

increase their fee schedules. And so as costs have continued to increase for

39:12

business owners, they are having to find ways. I was in a team meeting this week

39:17

where um there was a patient that came into this practice, received a treatment plan. This is an out of network office.

39:24

He was like, "That feels expensive to me." He went to an in-et network office. Got

39:30

a treatment plan from them. That treatment plan was $4,000 more

39:37

than what the estimate was from the out of my client's office, the out of network office. That man came back,

39:45

brought his treatment plan, showed it to the doctor that had provided the original estimate, and he was like,

39:50

"What's your take on this? Why is this $4,000 more?" Cuz that was in network. I thought it was going to be cheaper.

39:56

That's because things like anesthetic were on there. That's because infection control fees on there.

40:02

Infection control I think was on there. Um, uh, sensitivity medication was on

40:09

there and that office and this is not every in network office. I'm not casting

40:15

judgment here. This particular office that that my client told me he said there were about six fillings on there

40:22

that were not fillings. He was like, I checked those. It was acclusal staining.

40:27

There was no stick. I thoroughly evaluated that and those were not things that needed to be done which again now that now we go down that

40:34

thing now now he said she said and which dentist is right and which one's shady because one of us is shady or are you in

40:41

are you inept that you didn't catch these decay areas or are you uh what's

40:46

the word the uh supervised negligent you know these are cavities you're just waiting for them to get to be crowns

40:53

that's why it's not on your treatment plan but this doctor or is it that doctor's too aggressive and these weren't decay like now we're going down

41:00

that path and I will say like I at the risk of people going you you are

41:07

awful and I don't mean it that way but it's just human nature to think what goes up comes down what goes in goes out

41:13

right like so if how are you able to maintain your your fees and all

41:21

it's not like your staff is going to charge you less it's not like your rent is less like we all have the

41:28

payments to be made. So, how else are you going to make money? Well, suddenly now that tooth needs a pulp and a crown

41:34

and that tooth needs and so I I'm not I'm not saying if you take insurance

41:39

that's what you're doing. Like I don't I'm not don't mean to say that, but I'm just thinking for me from a if I was outside the industry, you got to make

41:45

your money somewhere. Yeah. And so, um and it may be that that maybe those

41:51

teeth were in gray areas. It's like could go this way, could go that way. And because bills have to be paid, it's

41:57

like, okay, I may incline myself a little bit more towards the aggressive path because that's what I have to do.

42:04

And so all that to say, I think the the common misconception is it's going to be cheaper if I go in network. And I've

42:11

been saying it for years. That is not the case. That is just not the case. But

42:17

how do you then like I can't say that to a patient. I can't say, "Yeah, go ahead. go to your out of network and see how

42:22

many more things they rack up onto your thing like that. That would be awful and

42:27

necessarily and whatever. And so you can't sit and wait. Luckily, again, I'm I'm to where I'm like what 5 years, 7

42:35

years away from being like, I'm done done with dental, I'm walking away. So, I'm at the tail end. I can't imagine for

42:41

somebody who's just starting off and and you're having to do all this. I'm in a point where I can be like, you know

42:47

what? You don't want to come here and pay my fees, don't pay them. Yeah, I'm good, right? But I it's still a problem.

42:55

Yeah. And so I had to empower my team to say, I am not holding you to anything here. I would rather you let that patient

43:02

schedule somewhere else and you just be very clear of going, I don't know what your insurance is covering.

43:08

Yeah. I don't know. Yeah. And then just whoever whoever comes comes and whoever doesn't come doesn't

43:13

come. But I know not everybody can afford that and I'm saying that now. Am I going to be saying that same thing six

43:18

months from now? I don't know. But for now, that's how I feel about it. Well, and I think I think for now, how

43:25

you're feeling about it doesn't necessarily automatically equate to a system or a strategy. Right now, we're

43:32

connecting it to this is the way I feel about it. So, this is what we say. But I think the feeling itself, the the

43:40

disposition, the the position that you're taking on this is the right position in that we've got to find a way

43:48

to not be tethered to insurance. Number one, uh inner in or

43:54

out of network, it doesn't matter. We need we've got to have a clear mindset that we're not tethered to insurance.

44:01

um or what insurance says goes because that's a slippery slope down to talk

44:06

about negligence for a patient. That's what insurance will drive you to if you follow every rule that they've put out

44:12

there. So, we've got to be untethered in that way clinically. But we've got to also be untethered in a way that

44:19

patients realize the decisions that we make, the communication that we're having with

44:25

you. We're doing the best of our ability and that unfortunately leads to

44:32

uncertainty. We cannot predictably say one way or the other whether insurance is going to pay this. And however we put

44:38

that into a system or how we communicate that over the phone or in person or whatever, that's going to look different

44:43

for every office. But I think the core default has to be the same. We cannot

44:50

communicate with certainty when it comes to insurance. We can't. And if we're pretending that we can, we're doing the

44:56

dental field at large a disservice because that certainty can't exist. And

45:01

I think if nothing else from this episode, it's a good opportunity to encourage our listeners to to go back

45:09

and have this conversation again. Re-evaluate how are we addressing this? Is our default position uncertainty? And

45:15

if not, why are we acting like we can be certain? And then now, what is the system that we're building out of that?

45:21

un unless you're fine to write off everything that's not covered. Like maybe that is your strategy or maybe that which I yeah,

45:27

you know, good good luck with that. That's a dangerous slippery slope into itself. Um

45:32

yeah, but I I don't know. The whole thing to me was just like back here again. Like I don't know. But I've always had that

45:39

like on our paperwork. It's like, you know, I understand that insurance may not cover. I'm going to pay the whatever. And if a parent like writes um

45:47

I do not consent. And then we have a ton that write I I do not consent. I only want what insurance covers. I stopped

45:53

the appointment. I'm like, "Oh, no, no, no. We're not We're not doing your appointment." No, you're asking me for this to I have no idea what your

45:59

insurance is going to cover. Why don't we cancel today's appointment and go on? And they're like, "What do you mean cancel? I'm already here. I'm already

46:04

whatever. Are you telling me insurance going to pay?" Well, you are saying you only want what's covered. I have no way of knowing that. So, I'm not going to

46:11

get caught up in that and then we fight about it later. I'm telling you right now, I have no idea. So, if you want to keep the appointment, at most you're

46:16

going to pay this amount. Are you okay with paying that amount if insurance doesn't cover it? No, I'm not okay paying that amount. Okay, then we need

46:22

to stop. I don't know what insurance is going to cover. That's how much I don't trust your insurance company. So, I'm

46:28

I'm not going to get caught up in that. Yeah. Now, if you want to stay, and I would say eight out of 10 stay.

46:35

Yeah. Because at least for my patient base, they can afford it. They just don't want to because they feel like their insurance

46:41

is supposed to pay all of it. Right. So, and and then that's where I too kind of what you said before where I'm like, you

46:46

know, what industry is your home owners paying everything? Your car insurance pays everything. Your who who where is

46:52

insurance paying anything anymore? So, we're no different. So, if you want

46:58

the service, here it is. If you don't want the service, there's the door. I that's that's all I can offer you right now.

47:04

All I can guarantee is I will not tack on unnecessary things that your kid doesn't need. And I can guarantee I will

47:11

do my best to take care of your child's dental needs. That's what I can guarantee. Y I cannot guarantee anything else.

47:17

Yeah. If you need a guarantee, there's the door. Yeah. I can guarantee you won't find that anywhere else either. Bye-bye now. Like

47:23

I I just I can't. So um No, I think I think it's timely to bring

47:30

this subject back up. It unfortunately is a big part of our world. I I tend to

47:37

view it as the bane of our existence, but it has to be dealt with. And I think if we're burying our head in the sand

47:43

and just like, "Oh, it's probably all fine." It's probably not. And I think teams could benefit from re-calibrating

47:50

on this every so often, and now is a good time to do that, which I know you don't really want to do cuz now my next thought is, okay,

47:56

billing person, what else are you forgetting? Okay, front desk, how are you guys answering this phone? What are you

48:01

guaranteeing and what are you not? Do I need to start going and listening to those call audits? Okay. Now, so I'm just like, "Oh my god, this just I'm

48:07

just going to go bury my head again and be like, you know what? Just write off $3,800. It's not worth it, right?" Like,

48:13

that's what I want to do, but I won't do that. It's part of running the business and

48:19

putting my big girl panties on and I've got to take care of my business, so that's what I'm going to do. But

48:25

it's exhausting. It is. Thank you, insurance, for Yeah. And now also waiting for the

48:31

negative review and the board complaint. Yeah, those are all going to be also part of this equation. Yeah. Yeah.

48:37

Yeah. Why not? Why not? Yeah. Drama, drama, drama. Drama. Always drama.

48:44

Thanks for joining the conversation today. We hope that you are comforted in knowing that you are not alone. But we

48:51

also hope that you're walking away with some really great tips and tricks to try in your practice.

48:58

We value your feedback. So, please take a few moments to rate and review the

49:03

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are rooting for you today as you manage your dental drama.