Insurance MAD World Part One

Have you been asking yourself lately, “Where is all the money going?” Or have you noticed that certain procedures are simply less productive than they used to be? Maybe you’ve even wondered to yourself, “I feel like I’m working harder and making less, what is happening?” If these thoughts sound familiar, then tune into this episode. Dr. Kuba and Bethany spend time discussing current trends in the MAD world of insurance. The fact of the matter is in-network practices actually are making less now due to changes in insurance. Practice owners must equip themselves with the tools needed to evaluate what has changed, why it has changed, and what they can do about it. Insurance is, no doubt, a world than can drive one mad. However, it is a world that must be won by practice owners. Listen in as practical tips are discussed. 

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Transcript

0:01
Are you looking for a podcast where you can hear from real [music] people regarding their real dental drama? If

0:08
so, then you've come to the right place. Join hosts [music] Bethany Penny and Dr. Reena Kuba as we

0:15
dive into the solutions we've created [music] and the mistakes we've made while managing dental drama.

0:22
Let's [music] get started. Welcome to today's episode. I am excited to talk

0:29
about a subject that again I feel like we're revisiting some of the ones that we talked about many many months ago and

0:36
I feel like the environment has changed and we need to revisit some of these

0:41
subject matters. So one of the subjects that is coming up almost on a daily

0:48
basis for me right now is insurance. And we had an episode h gosh almost a

0:55
year ago where we talked about just the insurance changes and um how dentistry's really got to get away from its

1:01
dependency upon insurance. But in all honesty, there's been a lot of changes even within that last year. You yourself

1:08
have been walking through some insurance changes that I want wanted you to talk about with listeners so that they can

1:14
kind of understand the process that you went through. Um, [clears throat] I think this will be really helpful hopefully to all listeners to kind of

1:20
take a a new look at the insurance world. So, where do you want to start? You want to start with your example

1:26
first and kind of what you've been walking through? I I'm happy to. However, um, I guess to me it's it

1:33
wasn't really a planned, thought out, strategic. It's almost like, you know,

1:39
insurance is something that I try not to think about and to look at just because it's it's gotten so confusing. So when I

1:46
started, you know, 12 years ago with my own stuff, I remember negotiating my own contracts. I don't even remember how

1:53
like how did I get a hold of Signar or how did I get a hold of human? I can't even remember. But I do remember negotiating those. And

1:59
it has it like it is night and day different now than it was then. Um so a couple years ago, we hired a

2:05
company that helps us um what is the word they use? maximize or I'll come up

2:13
with the word here in a minute, but basically for example, I remember I resisted

2:18
signing up with MetLife initially 12 years ago because they wouldn't do any special um rates for a specialist.

2:26
Mhm. And I was like looking at their fee schedule and I was like this is a joke, right? And so for the first like six

2:33
months, eight months, I didn't um sign with them. And then a lot of our patients were midlife patients.

2:41
Yeah. And um so I finally just kind of bit the bullet and went okay even though paying

2:47
being out of network they still pay but patient understanding of that. And of course back then I didn't have great

2:52
verbiage to not that not that it would have mattered honestly my patients wouldn't have mattered. They I think they were always suspicious of going

2:59
you're out of network never mind and not even listening to anything else. So, um I think with um MetLife I

3:09
ended up I finally got frustrated like I was with them for a couple years and I think so I I literally was just was like I'm

3:16
quitting and I dropped it. Well, it turns out then like this company helped us now cuz there are all these like

3:22
parent companies like Carrington for example. I think there was one called Dentamax we were with for a while and so

3:29
these parent companies that have this big umbrella and so they negotiate with

3:34
Metife for you. So you can be in network with Metife even though you're not in

3:40
network with Metife and I'm like what are you saying here right now? like we talking in circles or I'm missing but

3:45
it's like I could either be directly in network and or be I forget the word that they're

3:52
using I I call them umbrella companies. So some of them you know are contracted

3:58
under these umbrella companies. It's their way of sneaking into optimization. That's the word they use.

4:05
This company uses we optimize. So yes. So this umbrella company for

4:11
example Carrington. Yeah. and they have their own negotiations with MetLife PDP plus plan.

4:18
So, not all MetLife plans, but this one. And then they have an a a sub contract

4:24
with I don't know, United Healthcare, but it's only these certain United Healthc Cares and then Blue Cross Blue

4:30
Shield. So, patients would say, "Well, are you a network with them?" I'm like, "I really don't know because do I have a direct that I have reached out to Blue

4:37
Cross or they've reached out to me and we've signed something?" No, that's never happened. However, because we are Carrington, we do have a contract with

4:44
Carrington. And this year, Carrington happens to have a negotiation with Blue Cross. Exactly.

4:50
So, it's just gotten more convoluted and it's really hard to tell. So, when people ask, I'm like, I really don't know. It's going to depend on your

4:56
employer, which of course then the backlash is on the dentist. What do you mean you don't know? You're trying to be shady, [laughter] you know, all of that. I'm like, but I

5:03
don't think they really understand the the complexity we're up against. Yeah. Anyway, so I'd gotten out of

5:09
network with MetLife years ago just and basically [laughter] zero strategy behind that. It was really

5:15
just me having a temper tantrum. I'm not even kidding. I finally was was super annoyed. My patients are very needy in

5:23
how many discussions we have to have. There are a lot of our patients that don't understand what a cavity is. No

5:28
joke, just yesterday alone, I had a dad first thing in the morning and he was like, "But we've been brushing really

5:34
well." Uh-huh. Well, won't that take care of it? No. There's a hole there,

5:40
sir. You've got to repair, you know, patch that up, right? Um, so my patients are very very needy

5:47
with how much time they need. They're going to call multiple offices. They're going to, you know, so anyway, all of

5:54
that back in that time, we we may have gotten three phone calls regarding an

6:00
acclusal composite on tooth A, right? and each of those phone calls lasting between 30 and 45 minutes.

6:08
So knowing and this was back in the day. Let's assume it was cheap and I was paying my front desk $10 an hour which I wasn't right pre-COVID that was

6:14
possible. So you know what I mean? So like three 30 minute phone calls for easy math was

6:20
going to cost me I don't even know what is the math on that 15 bucks right? Well, when Metife is gonna pay me

6:29
30 bucks, [laughter] this is not adding up. This is not adding up. And so, I think I

6:35
just had one of those moments where I was like, "This parent was ridiculous. The kid was difficult to get the

6:41
treatment through and I was setting complete. We have dentrics. I was setting complete." And I glanced at the

6:47
ledger and I I just about I mean, I don't know how I [laughter] kept the exploive in my head, but I was like, "Are you kidding me?" Like, that is what

6:53
I got paid. I think I lost money on this and whole, you know, exchange because of

6:58
the number, how much time I had to spend talking to the parent, how many phone calls they made, how much time I had to

7:04
spend with the kid. Like, there is no way if I got paid anything on that, I probably got paid 10 bucks if that.

7:09
Like, it it was foolish. And I think that's the day I was like, I'm done. I'm done with Med Life. There was also a

7:15
point in the practice, I think the practice had been there about fourish years, and I um was really not liking my

7:22
staff. this right around when we hired you. But I was like, I hate the staff. Um, I hate this Met Life, so fine. We're

7:29
going to drop it and I'm going to lose a third of my patients. And good, because

7:35
then maybe I can let the staff go, too. So, this will be fine. Um,

7:40
anyway, moving forward to now, how are we getting out of insuranceances

7:45
and how are we doing all of that? I mean, it is I think we're back to the last podcast. We talked about this back what last September, August, whatever it

7:52
was. Um we talked about mostly for me at that time was Medicaid was the most recent thing we had dropped uh in 2020.

8:00
Correct. Because of the pandemic and um just not being able to keep up with, you know,

8:06
when Medicaid's paying you $18 for an exam and my N95 was $10, but I got to

8:12
get one for everybody on the team. Like I that's not sustainable. That's not going to happen. Um, and then the extra person that I had to hire to make sure

8:19
that Medicaid would pay the $18. Yeah. Because the mom had to designate me as

8:24
the provider because I wasn't designated the provider. I'm not going to get paid that $18 bucks. So all of those

8:30
logistical things was just like I I'm done. I can't do this anymore. So now looking forward as we've been

8:37
Yeah. Well, and you found out so even though you had dropped Metife all of a sudden, and this is again going back to

8:43
your complexity term. Um, you have associates on staff and these umbrella

8:49
companies have come into play. So then all of a sudden your insurance lady is letting us know, I don't know what's

8:56
going on, but we're getting in network reimbursement from Metife. And you're

9:01
like, wait, wait a second, we're out of network with Metife. So it gets even more ridiculous than that. Okay. Um and

9:08
and to say that I've figured it out, I still haven't. That's how cloudy it is. And um and so shady comes to mind,

9:15
right? And so and so I think this is where I take it kind of, you know, I take it very personal for our profession. I think we are thought of as

9:22
a shady profession. Um and I think this is why because there all of these things out of our control

9:28
and we look like the bad guy. Yeah. Consistently. And um and now it's gotten

9:33
even worse. Like you'd think 2022 would get better. And I know the ADA is always fighting for, you know, insurance

9:41
transparency and all that, but there's only, you know, there's so many fights they can pick with the Senate and then

9:46
how every state decides to. So it's it's a big machine and it's big and blurry. The point is it still has not gotten

9:52
better. It's gotten worse. And um I think now and kind of looking at you

10:00
know the aftermath of the pandemic this far along and what we've talked about in our last couple of podcasts that it's

10:07
not getting better um with with staff and so I hate to be a negative Nelly here. I'm just I guess I'm just kind of

10:13
sharing what I've kind of been through and um hoping that we try to get some tips out of this. So, um, so we we were

10:22
going to come back to revisit this in another podcast, I know, but, uh, it's still kind of raw for me at the moment,

10:28
but when I say there's been drama in my office, you've been front and center. Um, lightly pro.

10:34
That's putting it lightly. Um, and it started midFebruary, and I thought February was awful, and then what's

10:40
transpired in the last two weeks was just, um, stuff I never thought I'd deal with. And um you know I I'm grateful to

10:49
you because I I I don't know. Anyway, it's still kind of raw. I'm not ready to

10:55
talk about it just yet. But all of suffice it to say as of today, this hour

11:00
as we're talking, I'm sitting here going, "Okay, I'm going back to the why

11:06
and what and then and then the what and the how." So, if I like this whole staffing situation

11:14
is so dire right now and I'm wanting to kind of clean house, but if I clean

11:19
house, if everybody I didn't like, I would be left with two hygienists, maybe three, um, two assistants and one or two

11:27
front desk and my AR person. [clears throat] So already we've got maybe three more

11:33
people on top of that right now, but and it's still not enough to see the patients we need to see.

11:39
Yeah. And I I want to get rid of more and you're advising me not to and I hope I listen to you, but that's another

11:45
conversation off off the record here. Um [laughter] to be continued on that. To be continued. Yes. Uh because I'm

11:52
just I'm just tired. I'm tired. I don't have time for the riff raff. I don't have time for the oh I can't come in

11:58
today because I don't feel good with this or I'm just tired. Do you want to work or not? Yeah. And so anyway, let's

12:05
get back to insurance with this. So I think for me kind of looking back at it going this is not sustainable anymore because

12:11
insurance reimbursement is so crappy. It's getting worse. Patients have gotten to an all-time level of craziness.

12:18
Staffing has gotten to an all-time just defeating, deflating, maddening. So,

12:25
what what what game on the chess what piece on the chessboard am I playing? So, then we started looking and going,

12:31
okay, well, maybe it's time to drop another insurance because I cannot keep seeing all these patients with the staff

12:37
I've got right now, right? And um so we looked at Delta, like I

12:43
keep wanting to drop Delta because that I mean like I looked at the reimbursement the other day of something

12:48
that we did. It's laughable. It's ridiculous. Um, and I thought, golly, I

12:53
just want to get off of Delta. So, we reached back out to our company that's supposed to help with this. Um,

13:00
I'm not giving them a shout out right now because I am almost not a client anymore of theirs. So, I will keep their

13:06
name out of this podcast. I don't think I don't know if they listen to it or not, but anyway, I don't have nice things to say at the moment, but

13:11
[snorts] um, that's another podcast. [laughter] Hopefully, they will redeem themselves. If not, I don't know. I I keep chalking it up to

13:18
they're also having staffing issues, but they are. Anyway, um anyway, reach out to the company and say, "Hey, can you

13:23
look at our numbers, our stats, you know, what kind of hit are we going to take if we drop Delta?"

13:28
Yeah. So, somehow from that conversation, I think where we ended up with that is our

13:34
newer associate just signed a Delta contract. So, if I get out of Delta and

13:40
he's in Delta, then all the Delta patients are going to fall to his schedule, which means he's going to get paid

13:46
like garbage, work his tail off, and then he's going to leave my practice because he's seeing all the Delta

13:52
patients. Okay. So, we can't we can't drop Delta at the moment. So this company, this company that that

13:58
optimizes and negotiates our contracts for us now was like, well, the next one that's lowpaying would be your MetLife.

14:07
And so I kind of was like, well, we're not in direct MetLife. And sure enough, we're through this Carrington umbrella.

14:13
And it just got more convoluted from there because apparently for three years

14:18
we have known that I do not show as an in-network

14:24
dentist under Carrington with MetLife, [laughter] but two of my associates do show as in

14:32
network under MetLife through Carrington. And now the new associate is with me. So you've got two of us that

14:38
are and two of us that aren't. Okay. So now what does that mean? And

14:44
what do you mean? This has been going on for 3 years. And so my manager, my AR person's like, "We've been trying to deal with with this company that's

14:50
supposed to optimize for us to get that fixed." And again, this company, I guess,

14:56
seemingly didn't know what they were doing for 3 years. And again, I guess at the end of the day, it didn't really matter. Like the AR person was able to

15:03
frankly, I don't even know what she did. Yeah. How we get around. In theory though, the two that are in net in uh

15:10
network with MetLife under Carrington under Carrington were getting paid Carrington fee

15:16
schedule. But now for some reason they've decided

15:22
to start paying the MetLife fee schedule. Yeah. So, I was like, this is all sounding

15:27
very like we need to get to the bottom of this because the whole thing is weird and it needs to be very transparent and

15:33
I don't like when things are weird and because ultimately it comes back on us. Yeah. So, how do we fix this? So, [laughter]

15:40
apparently if I come in with MetLife won't do less

15:45
than a 15% write off write off. But if I for for me to get technically

15:53
in network with MetLife through Carrington, right? But if I do that with MetLife through Carrington, if I agree to the 15%, then

16:00
I've got to agree to the 15% across the board with all of the negotiations

16:05
with Carrington. Which right now I'm at a 10%. So why would it's a massive loss like

16:11
why would you do that? So why would I do that? Um, and then something if we if we fix something then

16:18
the ones that are in are going to take a hit on. This is where I get lost. And frankly, I just hit the off button. I'm

16:24
like, I I will never see like this whole thing. You know what? Get us all out of

16:30
MetLife because two one of the associates started her own practice earlier this year, so she's gone. Yeah. The other one is about to leave next

16:36
month. Yeah. So, he's gone. So, that leaves me and the one who weren't on it to begin with. Mhm. I don't know, man. But so now I

16:45
guess it's kind of a I guess we've kind of been out of MetLife, out of network but kind of in network. [laughter]

16:51
I don't know what to say. I don't know how to qualify it. Um but apparently now we are Oh, here's the next onion layer.

16:59
So I guess when you drop like if I was directly through MetLife with MetLife and put Carrington aside and I decide to get

17:06
out of contract with them, I have 90 days I believe. So I can say, okay,

17:12
here's my letter MetLife on May 1st and 90 days from that I know I'm going to be out of network. So I can plan my

17:18
strategy on verbiage for what am I telling the patient? Am I sending a letter? Am I So and I know you've got thoughts about that. So we can talk

17:24
about that here. Um am I sending a letter alerting my patients? Like what is our our strategy for alerting our

17:30
patients? Well, it turns out that since me being in network, sorry, some people

17:39
in my office being network by you [laughter] with MetLife through Carrington, it is a

17:45
opt-in. So, it is optional for me to be in network with them. So, I can opt

17:52
out. Opt out. Great. Well, they don't have to tell us when we are opted out. [laughter]

17:59
So it could take a week or it could take two months, right? Okay. Well,

18:04
now there's this new unknown, right? And apparently if I was with directly with MetLife, MetLife would

18:10
send a letter to the patients alerting them that we are no longer in contract.

18:15
When we opt out, MetLife won't be doing that. So all of that comes on us. So actually, now that I think about it,

18:21
it's probably a good thing cuz who knows what MetLife puts in this letter. probably your dentist has opted not to

18:26
help patients and has who knows what they can say about us. So I so maybe this is good this is that this is in our

18:33
hands. Well [snorts] so in our particular situation because of this company and their staffing issues let's

18:40
be kind and put it that way and go with that assumption. Um I had to follow up and I asked okay so where are we with

18:48
this opt out? Oh well didn't you get the papers? No, didn't get any papers.

18:55
Story of our lives the last 3 years. Nope, didn't get the papers. Can you please send them? Um, and being the very

19:02
um I have had it person now, like I can be nice for a long time and I have had it and then I'm not very nice and I am

19:09
copying the president of the company on every one of my emails now. Um, and so, uh, I'm like, I'm going to

19:15
be that squeaky wheel now. Like, I am sticky and oily and I am coming. [laughter]

19:21
I'm not being nice anymore. So anyway, so finally he starts replying and um they had the nerve, poor company, had

19:28
the nerve to send out a an evaluation. We value our clients and we're always trying to improve. Oh my gosh, I did not

19:34
hold back. I was brutal. But again, it wasn't just me having a little beef fest. I

19:41
really do feel like, okay, if you're saying you want to help, yeah, then you need a wakeup call because this

19:47
is and they, you know, they're constantly sending emails out, oh, we strive to do this and I see them on the ADA or the A

19:53
like whatever it is. We're doing this seminar and I'm like, you're full of nonsense. Look at yourselves and really look at your services. Yeah.

20:00
So, I think the direct the very direct unfiltered feedback

20:05
if they're listening and maybe you just went to spam for all I know. But at least you felt better getting the

20:10
At least I did. So well and their job it's the primary reason that they exist

20:17
was not being managed in your practice because again all this time you've been

20:22
out of network with MetLife and then through this convoluted mess of the insurance world you are not in network

20:31
you're two of your associates are under the Carrington umbrella with MetLife PDP Plus but that still messed up claims

20:39
that even you being completely out of network were being paid on. Um

20:44
not to mention then the fee schedule got weird uh where they were paying far less

20:49
which is again one of the things that your AR person noticed like what's going on? Why are all of a sudden are we

20:55
getting super it's just to me that story is an example of how messy this

21:03
insurance world is right now because you thought I got a clean break from my

21:08
MetLife. I'm done. And yet somehow through all these weird contracting, you're somehow connected with it or two of your

21:15
people are. And then even the fee schedule that they should be using is not being used because it's all of a

21:21
sudden the MetLife fee schedule. So I think you just pointed out cuz that that that for me that that sheds some

21:28
light because to me I think this whole time because it's not like we've just been under Carrington for this year.

21:33
here. I mean, we've been in for about 4 years now, and I hadn't heard a peep from our AR, and it seems like it's not

21:39
bad. And I think that's what happened now in the last 3 months, she was like,

21:44
"Wait a minute. All of a sudden, we're getting paid on MetLife's fee schedule, not the Carrington fee schedule."

21:50
And so, I guess whatever's gone on between Carrington and MetLife, who knows? And maybe they're all trying to recoup losses and MetLife MetLife is

21:57
hoping nobody notices. Or maybe they have their own like fine print stuff with I mean, like, we'll never know. But

22:03
you're right, that's what's happened these last couple months. So she finally was like, "Wait a minute. What is this?" And then that's where the onion layer

22:09
exploded. We're like, "Wait a minute. I'm not in network, but I'm not ever going to be because then I have to take this. I got to do that." And like, "What

22:15
am I paying your what am I paying y'all for? Y'all are supposed to be looking out for that." Yeah. Um, and so we finally were just like,

22:22
"You know what? We're we're out now. When I call, I ask, when are we opting out? when are we? Well, they're not

22:29
going to tell you when you when you know, like you'll just have to you may figure it out midday. Like you may log in in the morning and see that you're

22:35
still listed as a provider and then by 1:00 you might be listed as out. They're not obligated to tell you."

22:41
Yeah. How is that even legal? But okay, well, you're saying my paperwork was submitted. Can you at least tell me

22:47
that? Oh, we submitted it for you on March whatever. I was like, okay, so if you're saying it takes about four weeks, it

22:53
could take a week to about four weeks is the usual time frame. So, we're there now because this was at the end of

22:59
April, [laughter] couple weeks ago. We're there and they're like, "Um, yeah. Okay. So, when were you going to tell us

23:05
that this was we need to start communicating with our patients on this?" Yeah. So, then you can only imagine the email I sent the president of this

23:11
company at that point. Um, and then we are having to scramble and mind you, we're already having every

23:17
staffing issue under the sun right now. So, for us to scramble on this and my office manager was like, "Oh, well, I

23:23
was going to work on this." I'm like, "No, no, you don't understand." Yeah, we've got to work on this today.

23:28
Yeah, yesterday. I think even you were like, "Okay, we can talk about it then." I was like, "No, Bethany, I don't think you understand. This is like happening as we

23:39
speak." Yeah. Because apparently they opted us out a month ago, but didn't tell us they opted

23:45
us out. Even when I asked last week, they were asking me if I gotten the paperwork. Well, apparently somebody

23:50
signed this paperwork and submitted it back at the end of March, but nobody knows who or what or why. like it is a

23:56
cluster and so anyway I think you had a point of why I'm sharing all

24:02
well to me it's it's a good metaphor for not just with MetLife but what I'm seeing

24:08
across the board with just the confusion of insurance I mean I can remember a

24:15
time I mean I've been in the field a long time but I can remember a time where it was cut and dry and it was

24:20
simple and it has become increasingly complex And to add to some of the things

24:25
that you saw on your side, some of the things that I'm seeing on my side, um I was at a practice yesterday and she has

24:32
been noticing and this will be one of the tips that we'll make here in a minute, but good detail person that was

24:37
managing these these uh insurance checks and she was noticing a company that was dropping payments by cents, like cents

24:45
on the dollar. It'd be, you know, dropping 25 cents this time, dropping 75 cents next time. So she noticed she

24:53
because she was super detailed and she knows how that fee schedule. She's like, "Wait a second. Why are these things

24:58
being so literally trickling down the decrease?" And thankfully she's aware

25:03
enough to notice. Um I had one office that I was in, actually a pedo office

25:10
where their you know rule of thumb is we take a pano at about 6 years old at

25:15
least when the molars erupt. That's when we're taking it. That's been their norm. That's what they do. That's their

25:20
standard of care. All of a sudden, they've gotten some payments from insurance company or some checks from

25:25
insurance companies saying, "Oh, we don't start pano coverage until 8 years old." Really? Well, that's quite

25:33
unfortunate for not know that. Yeah. So, that's a new change. A lot of

25:38
insurance companies are applying deductibles to x-rays now. So, this whole free cleaning model is going away

25:46
in my opinion. It not it's not gone yet. There's still some that pay in full. Um, but I think that's what they're trying

25:52
to do. Um, I've seen the, uh, percentages being dropped. So, you know,

25:59
preventative has historically always been 100% and then, of course, if you're perio, it's a different percentage. But

26:05
now I'm seeing just regular preventative care. A lot of those are being dropped to 80%. Now, patients aren't being

26:11
informed. They're not. They're confused by it just like the dental office is. It's like when in the heck has 80% been

26:18
normal on a preventative appointment. So, we're scrambling, dental offices are scrambling in the moment to try to get

26:23
good answers um for these for these patients. Um, of course, you have heard, I'm sure,

26:30
about um companies that are a little bit more bold in their cuts. So, Sigma is one of the big companies that um even

26:38
sent out notices to all of their in-network offices saying, "Hey, we're just cutting like it was from a range of 10

26:44
to 20%." You know, we're cutting by 20% across the board. So, that's your new

26:49
fee schedule. Basically, take it or leave it. Um which is a massive a massive drop. So, I would say in

26:57
addition to all of this convoluted, am I in network? Am I out of network? What about this umbrella company? and how do

27:02
I maximize this and optimize that? It is mindbogglingly, you know, bogging and confusing, but

27:10
also just all the other stuff that's changing with all of these little random random new rules like X-ray frequencies.

27:16
And so, how does that work? Like if the patient like say their company, say uh

27:22
Costco negotiated with Delta Dental, like does I'm assuming then does that

27:28
contract say that they can change their fees whenever they want? they can change their coverage whenever they want. So, how is that legal then for as a

27:35
consumer, as a patient to purchase this insurance? Yep. And also

27:41
on that note, speaking of contracts, I just was reading through some new contracts. So, insurance companies, this

27:48
is again something that's really irritating about them, is they're very

27:53
careful with putting that contract out. It's like literally tackling Fort Knox

27:58
to get a copy of your contract. I've had offices that request, "Can we please have a copy of our contract, our

28:04
contract, our contract, and just never comes." Oh, yeah. We're going to fax that to you and it never comes. Why are

28:09
they so picky with their contract? Because they're not in contract. We're in contract with whatever they say their

28:16
contract is in that moment. So, I got this new contract um from a startup uh

28:22
client of mine and I was like, "Hallelujah. I'm finally getting to read a contract. I've been trying to look at

28:27
one of these for years and I can't seem to get my hands on one." And so, this was a fresh one that I've had in the

28:33
last couple years and so I was reading through all the fine print. Uh it is

28:38
unbelievable what they want that in network doctor to agree. Yes. Yes.

28:44
And they're sign they're initiing on those lines. So, one particular line that stood out to me in this contract

28:51
was um anything on the EOB that says, you know, patient does not owe, the

28:59
doctor agrees not to charge the patient for that. That sounds all reasonable and fine. I mean, on the surface, you're

29:05
like, okay, yeah, I get that. Except when I am looking at claims day after

29:11
day when I'm auditing and I see a claim that says, you know, treatment breakdown and there's nitrous,

29:18
which is exorbitantly expensive right now. So nitrous, you know, whatever,

29:23
$75, patient pays zero, insurance pays zero.

29:30
Mhm. So now Mr. your new doctor has signed a contract that says, "Okay, basically I

29:36
provided nitrous as a service, but I agree to this contract that says that I'm not going to charge the patient for

29:42
that." Holy moly, no. It is not legal. Especially in the state of Texas, this will be for our listeners that aren't in

29:49
the state of Texas. Um, they'll have to look at their state laws, but in the state of Texas, we are protected by a

29:54
law that says the insurance cannot dictate what we charge the patient when something is not covered. Period.

30:01
Thank goodness. End of story. So for that, so when I was looking at this contract with my client, I said, "You

30:08
are going to be signing this contract because you're going to network with this company, but you are going to break that contract on day one, and I want you

30:14
to know you're just going to have to be okay with that." Um because they can't have you agree to that. It's unethical.

30:20
It's illegal. Blah blah blah, right? And that's the only time he'll ever see that contract again. Let's say 10 years from now, he's still in network with that

30:25
company. They will not produce a new contract for him. So it is completely a

30:31
dysfunctional relationship. Yeah, for sure. Um, well, I mean, that's where again,

30:36
and I want to say it was Medicaid. Um, maybe it was maybe it was a different insurance company, whatever, but some of

30:42
the fine print in there that says, I'm on call 24 hours. I will see the patient

30:48
at, you know, like whatever, like some crazy something. Um, and I was like, and

30:53
then yeah, I could get sued by somebody for not like coming in at 3:00 a.m. for

30:59
the cleaning they want. So there's a lot of things that I haven't signed in the past because I'm like this is

31:05
Yeah. weird. Yeah. Um Yeah, it really is. And it's to me the

31:11
point you made earlier is it's always been kind of a weird I think setup or confusing, but um

31:20
ultimately it's gotten much more confusing over the last couple years. And I think insurance companies are

31:26
making a lot of changes that make it more confusing. One of my tips, which is you referred to her, um, your account

31:33
receivable person and the one that I was talking about are detailed enough that they're noticing the changes. They're

31:39
they're reading through that EOB. They're not taking it just at face value. So, a lot of offices have AR

31:45
people that will look at that EOB, drop straight down to the patient pays

31:51
portion, and that's what they assume, and they zero out the rest. And we

31:56
cannot have that happening anymore because EOBS are getting very tricky. I

32:02
was literally looking at an EOB the other day and I look at EOBS all the time and I was going, what am I missing here? The math is not adding up adding

32:10
up. I spent 15 minutes digesting that stinking EOB to figure out what the

32:16
patient actually owes, not what that um column says. And I thought to myself,

32:22
this took me I've been in the field forever, pretty good at math. And I sat there and looked at that EOB and it took

32:27
me 15 minutes to figure it out. And so we've got to support our AR people.

32:34
First of all, we need to have as good of one as we possibly can. Uh you've got an excellent one. Um, but they've got to be

32:40
detailed enough to read fine print, to look at those little clauses at the

32:45
bottom, and to find their loophole for charging the maximum dollar amount. I think somebody like you have, she's been

32:52
in the field for a long time. She's looked at thousands upon thousands of EOBS. So, her eyes are just tuned to see

32:58
what's wrong with a claim. Um, and so she's super valuable for that. She is

33:03
the one that alerted us to the fact that all of a sudden MetLife was paying these weird fees. Thank god she did because

33:10
that opened up this whole Pandora's box that you didn't even know was going on behind the scenes. So I think every

33:16
office needs to have a good person looking at their AR. I think if you

33:21
don't have that and again a lot of you know startups or younger practices may not have the ability to have this really

33:28
great AR person then the doctor needs to become proficient in really looking at those EOBS which sounds awful but it's

33:35
better than money walking out the door. So, I mean, I think that leads to a bigger problem and possibly another

33:40
podcast here. But again, kind of where I started going, I can't stand my staff. Like, I can't find anybody that I can

33:47
stand. And even the ones that I've tried, we we recently let one go at the 90 days. Like, who let somebody go right

33:53
now? Like, who's letting people are like, are you out of your mind? We can't find anybody and you let somebody go.

33:59
Did she steal from you? Did she curse at a patient? Did she bring a gun into the office? No. No. No. We just all couldn't

34:05
get along. Are you out of your mind? Yeah. Um, and then I'm wanting to let another

34:10
one go, maybe two, and you're going, I wouldn't do that [laughter] for you. But I'm just like, I'm tired. I'm so tired.

34:16
If I'm going to have to go back and start reading my own damn EOBS, then I get something, you know, like maybe I only want to read 10 of them then. Like,

34:23
you know, I've only have support staff to see 10 patients anyway. You again in pedo, 10 is like what we see in the

34:30
first hour of the morning. So, um, you know, for general, y'all are probably going, "What?" No, for

34:36
yeah, for us 10 it's like that's what we see between 720 and 8:20. And so I think

34:41
but that's where I'm kind of like okay well that's what I've got the support staff for and maybe I'm dropping I'm going cold turkey out of just going fee

34:48
for service like you know that that's what I want to do like what's the best way to solve this problem. [laughter] So, you know, all or none. Um, which has

34:55
always been my personality. So, I've Thank goodness for Bethany to to coach me through. But, um, again, yeah, if I'm

35:01
going to have to do my own AR before long, and yes, I love my AR person. She's been with me forever. But, I'm

35:07
going to go back to what I said before. February has been where the bottom has dropped out. I trust no one anymore. I

35:13
trust no one. I trust no one. Um, and so she says she's happy.

35:19
Yeah. Let's hope that's true. I take that with a grain of salt at the

35:24
moment. Um, so I mean, this is good for me to know that the reality really may be because I'm thinking in my mind,

35:30
okay, I'm have to scale all my own patients. I'm going to automate the front desk. I'm going to figure out how to automate all of that and um call my

35:36
cousins in India. Hey, doing call centers still like what are we doing here? Um, [laughter] you know, like I'm just trying to think

35:42
outside the box to see but like could I have automatic check-in and automate all of that? I'm working on it.

35:48
Yeah. That way I don't have to have a front desk and that I don't need a hygienist because I'm going to do all my own scaling and then I need an

35:56
assistant. So it's like me and one other person and so now I need to add AR to my list. You too.

36:01
Okay. Got to go back to do those exact. Unless you want to do the EOBS. Unless I only take cash.

36:07
Unless you're fee for service and they have to file their own claim and then you don't have to worry about it at all. Is this where I need to learn about

36:13
crypto? Exactly. [laughter] career number two. You never know.

36:20
That's all I got for you. That's all I got. No, I I really do. I mean, it sounds crazy that that would be my suggestion,

36:26
especially in light of our last couple of episodes where we were really focusing on reducing stress and all of

36:31
that. Uh, you know, to think of a doctor having to look at EOBS if if only if you

36:37
feel like you don't have somebody that's super detailed and and proficient. Um I think the other suggestion would be

36:43
randomly audit um some some EOBS just to have familiarity with what are they

36:49
saying because it it is a skill to actually learn how to read that EOB. Um

36:54
so I think even just the practice owners becoming proficient in what does this say and and where do I buy the hours and

37:01
the days to add on to [laughter] cuz if it took you 15 minutes. Yeah, that was a complex one but yes.

37:08
Yes. And it may not be a daily thing. It may be once a month, you know, you ask

37:14
your AR person, "Hey, hand me a few claims um randomly." And just flipping

37:19
through and getting familiarity with them, I think would be good. Um I think it's ideal to have a strong AR person.

37:27
Do you have a number to a good DSO? [laughter] That's my take home from this.

37:35
Nope, I don't. [laughter] They do not. Well, I won't say that. No,

37:40
I don't. I'll stop there. Um, okay. So, that's tip number one. Get you a good AR

37:46
person or keep your good AR person if you have one. And then I think tip number two would be to audit a few EOBS

37:53
just on a monthly basis. Um I think the third tip that I would say is

38:01
it is worth watching numbers a little bit more carefully right now as far as

38:07
write-offs are concerned. So, I'll give you an example. A client that I was with yesterday and um we've been working on,

38:16
you know, I think all dentists for the most part have this really big heart and they're like, "Oh, I feel bad charging

38:22
that amount. Let me charge less for, you know, gosh, that feels better to me. Like, I want to take care of this

38:27
patient, so we're going to write off some." And so, we've really been working with this office on don't do that. Like, just your fee is your fee and we got to

38:35
make up for these increasing costs. And so we've gotten write-offs down. So

38:40
he's pretty much primarily in network and we've gotten him down to um about 39% write-off, which is pretty good for

38:46
an in-network office to be perfectly honest. Sounds crazy, but 39% is pretty good. [snorts] So over the last few

38:54
months, I saw it creep back up to 44%. And again, 5%

39:01
doesn't sound like a lot, but when you're talking $100,000, $150,000 a month,

39:06
that's massive. And so, we saw this creep back up. And then, as I was looking,

39:12
we we realized it was insurance write-offs, either elective write-offs, like,

39:18
oh, insurance decided not to pay for this PA, so we'll just write that off.

39:23
or actual write-offs where the computer said the fee should have been this, but when we got the check in it was $10

39:30
lower than what we were expecting, now we have to write that off. So those write-offs that also increased, all that

39:37
to say, it all added up to a 5% difference. And I think if a practice owner is aware of what is my steady

39:45
write-off and what is consistent, then if nothing else, even if you're not looking at EOBS, you realize, wait a

39:52
second, I was writing off 39%, you know, 4 months ago and now all of a sudden I'm at 44%. What in the heck is happening? If

39:59
we can catch that fast enough, then we have the strategy to be able to do something about it. And strategies could

40:06
be very well what you did which is I mean years ago when you were like forget it I'm done with MetLife like boom out of

40:13
network cuz that's absolutely an option. It could be that you're providing some

40:18
additional training for your AR person. Maybe she was writing some things off electively. She needs a little bit of

40:23
extra support. Um it maybe it's that you're rethinking your strategy

40:28
altogether on insurance. Um, but I think if we know that the write-offs have

40:33
changed, then we have the ability to do that. Um, I'm trying to think of any other trends that I could kind of

40:41
comment on. I feel like you knew about I feel like I've kind of bellyached about most of those to you, but can you think

40:46
of any other things that you've seen changing on the insurance side?

40:52
I I haven't. Um, just because I I I can't stand any of that. Right. I think most dentists, we don't we don't want to

40:58
look at the money. We don't want we want to do good dentistry and help our patients. Yeah. Um and of course we got to get paid for

41:04
it. That's part of it. But uh no, I think most of us definitely bury our head in the sand when it comes to this.

41:10
And so I guess if nothing else, like that's kind of good take home for most of our podcast is get your head up out of

41:16
the sand and take a look. At least look. It's not going away. Yeah. And I would say get you a get you

41:21
a good baseline. So don't just look at your numbers now cuz they're going to be substantially different than they were

41:27
for your practice 2 years ago. So go back, get that baseline from a couple years ago and see what's truly changed.

41:34
Um, it will absolutely have increased as far as the write-offs of what the amount that you're losing. You just need to

41:41
figure out if there's anything that you can do about it. Uh, and I think training your staff to prepare your

41:48
patients for balances. We don't know, to your point earlier, it makes us look shady because we really don't know what

41:55
to tell the patients. It's every day is a new day with insurance. And so we've got to do a lot of shifting of that

42:02
language to the let's see how your insurance, you know, we always hope that your insurance

42:08
is going to help you out on this, but we never know. So if they choose not to pay for something, we'll definitely send you

42:13
a bill in the mail. I'd much rather them be prepared for a bill and we've kind of primed that pump than to not say

42:21
anything and then they're mad about it. So, uh, this may be Well, I'm just going to ask you. We're going to have to dive

42:26
into it. I was about to say, do we have time to talk about this? And is this the right timing? Um, A, do we have time?

42:33
B, is the timing right? I'm just going to throw it out there. Well, I hate to leave you on a cliffhanger, but Dr. Kuba

42:39
and I dive into a whole new subject matter related to this mad world of

42:46
insurance. So, we go on for another 30 minutes and I wanted to break this up

42:51
into two different episodes. So, you'll have to stay tuned for part two of the

42:58
insurance mad world. Thanks for listening and I look forward to you joining us back next week. Thanks for

43:05
joining the conversation today. We hope that you are comforted in knowing that you are not alone, but we also hope that

43:12
you're walking away with some really [music] great tips and tricks to try in your practice.

43:18
We value your feedback, so please [music] take a few moments to rate and review the podcast. Finally, we want to

43:25
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43:38
that we are rooting for you today as you manage your dental drama.