Dental Insurance and Terminology Notes

Monday's Activities

  • Monday's class will involve either playing Kahoot or watching videos using the projector, depending on how quickly work is completed.
  • Participation is optional; students can choose to work on source assignments instead.

Dental Insurance Terminology

Importance of Understanding Terminology

  • For Practice Owners: Understanding terminology affects the bottom line, ensuring a busy practice is also a productive one.
  • For Office Managers/Front Desk: Enables tweaking practice management software and understanding reports.

In-Network vs. Out-of-Network

  • In-Network:
    • Agreement to provide services at a negotiated rate.
    • Obligation to follow the insurance company's fee schedule (participating provider).
    • Example: If an office fee for a crown is 1200, but the in-network MetLife fee is $800, the maximum allowable charge is $800
    • Exception: Some states allow charging the office fee for non-covered procedures, but state rules must be checked.
  • Out-of-Network:
    • No contract with the insurance company, so not obligated to follow their fee schedule.
    • Can charge the office fee for procedures.
    • If the insurance has out-of-network benefits, a claim can be filed to lower the patient's out-of-pocket expenses.
    • Example: Office fee for a crown is 1200. MetLife pays $600 as an out-of-network benefit. The patient pays 600 (the difference).

Production Numbers

  • Gross Production:

    • The dollar amount produced per procedure, which equals the office fee.

  • Net Production (Adjusted Production):

    • The most important number when taking insurance as an in-network provider.
    • Example: Gross production for a prophy is 100, but the Delta Dental fee is $60. Net production is $60 after the write-off.
      *Write-offs
    • difference between your office fee and what the insurance pays for a procedure.
      *If your office fee is 100andtheDeltafeehappenstobe100 and the Delta fee happens to be60, then the write off is $40.

Collections

  • The total amount of money collected from patients and/or insurance companies.
  • Forms of payment include checks, EFTs (electronic fund transfers), credit cards, and third-party financing.

Deductible

  • The amount a patient pays before insurance benefits kick in, typically for perio, fillings, crowns, bridges, or implants.
  • Some plans require deductibles for preventive services.
  • Calculation Example:
    • Plan has a 50 deductible for basic and major services.
    • Crowns covered at 50% with Aetna fee of $800
    • Patient Out-of-Pocket: (800 - 50) \% 50 = 375(Insurancepays);(Insurance pays);(800 - 375 = 425 (Patient pays).

Adjustments

  • Manual changes to a patient's account, including discounts, write-offs, or administrative fees.
  • Open Dental's built-in reports consider adjustments when calculating net production.
    • Example: Net production is 4000, but a $300 discount adjustment results in a net production of $3700

Appointment Schedule Examples

  • Recall Appointment (Periodic Exam, Periapicals, Bitewings, Prophy):
    • Gross production: 375 (total of office fees).
    • Net production: $166 (total in-network fee).
    • Write-off: $209 (difference between office fee and insurance fee).
  • Crown Appointment (PFM Crown):
    • Gross production: $1475
    • Net production: $889 (MetLife fee less any adjustments).
    • Write-off: $586 (difference between office fee and insurance fee).
    • If 50 courtesy discount is applied, net production becomes $839.
  • Collection:
    • The patient portion is supposed to be 494.2atcheckoutcollect494.2 at checkout collect494 for this appointment. Collection for the day is the sum of all monies collected, including patient payments and insurance claim payments.

Dental Insurance Overview

How Dental Insurance Works

  • Ancillary benefit supplementing health coverage, with lower premiums (around 50/month for an individual plan).
  • Monthly payments deducted from paycheck, often paid by the employer.

Types of Dental Plans

  • Dental Maintenance Organizations (DMOs):
    • Lower premiums but limited network of providers.
    • Specialist visits require referrals.
    • Usually no deductible; insurer shares costs from the start (coinsurance).
    • Often no annual maximum payout.
  • Preferred Provider Organizations (PPOs):
    • More flexibility in choosing dentists and specialists without referrals.
    • Higher premiums.
    • Have a deductible; individual pays costs up to a certain amount, then insurance shares costs.
    • Often have an annual maximum coverage amount (1000-$$2000).
    • Co-payment for certain procedures.

Coverage Categories

  • Preventative Care:
    • Usually covered at 100% with frequency limits (e.g., exams every six months).
    • Includes cleanings and X-rays.
    • Often no waiting period.
  • Basic Procedures:
    • Insurer typically pays 80% (coinsurance).
    • May include fillings, root canals, and gum disease treatments.
  • Major Procedures:
    • Insurer typically pays 50% (coinsurance).
    • May include dentures, inlays, and bridges.
      *Waiting Periods
      *Most plans require waiting periods for basic and major procedures.
      *Crowns (major procedure) coverage depends on medical necessity.

*Cosmetic Procedures
*Not Covered, including lightening, veneers, and some crowns.
*Orthodontics
*Coverage varies; braces may require waiting periods and exceed annual maximums.

Communication and Interpersonal Skills in Dentistry

Active Listening

  • Be present, set aside time free from distractions.
  • Repeat or paraphrase to ensure understanding.
    • Example: Patient says, "My sister had painful wisdom teeth removal; what if my medication isn't strong enough?" Respond with, "It sounds like you're worried about having enough pain relief."
  • Use paraphrasing, but not constantly or with factual information.
  • Lean forward, maintain eye contact, face the patient, ask questions, nod, smile appropriately, and keep a comfortable speaking distance.

Rapport

  • Establish trust and openness; be human.
  • Ask about interests, school, work, family, and hobbies.
  • Disclose personal information appropriately (e.g., bonding over sports teams).

Empathy

  • Understand and share feelings; show understanding and acknowledge concerns without focusing on your own experiences.
  • Example: If a pulp exposure occurs, acknowledge the patient's anger without dismissing it.

Nonverbal Communication

  • Be aware of body language; pay attention to eye and eyebrow movements to gauge patient comfort.

Verbal Communication

  • Be simple, specific, and direct.
  • Provide information and education instead of just giving advice; respect patient autonomy.
  • Avoid false reassurance; instead, manage expectations (e.g., explain that an injection may pinch).

Clinical Interviewing Techniques

  • Open-ended Questions:
    • Allow patients to explain what's important to them (e.g., "What brings you in today?").
  • Closed Questions:
    • Elicit specific information (e.g., "Do you require premedication today?").
  • Leading Questions:
    • Avoid these; they bias the patient's response.
  • Probing:
    • Gather additional information (e.g., "Tell me more" to find out about the pain).
  • Laundry List:
    • Provide a menu of choices (e.g., "Is the pain sharp, dull, constant, or throbbing?").

Treatment Planning Communication

  • Present treatment alternatives in descending order of desirability.
  • Only present options consistent with your standard of care.
  • Verify patient understanding using the teach-back method: have them repeat what they heard.

Basic Dental Terminology

Orientation of the Mouth

  • Lips: Outer border of the mouth.
  • Teeth: Used for chewing and speech.
  • Tongue: Aids in speech and taste.
  • Palate: Roof of the mouth, divided into hard and soft palates.
  • Uvula: Hanging soft tissue in the back of the mouth.
  • Tonsils: Part of the immune system.

Dental Arches

  • Upper Arch (Maxillary Arch): Upper jaw (maxilla) holding the upper teeth.
  • Lower Arch (Mandibular Arch): Lower jaw (mandible) holding the lower teeth.

Types of Teeth

  • Incisors: Four in the front of each arch, used for slicing food.
  • Canines: Two in each arch, used for tearing and holding food.
  • Premolars: First and second premolars in each quadrant, used for tearing, holding, and grinding food.
  • Molars: First, second, and third molars (wisdom teeth) in each quadrant, used for grinding and mashing food.

Dentition

  • Baby teeth (Primary Dentition): 20 teeth in total, erupt around six months of age, exfoliate by age 12.
    • Four incisors, two canines, and four molars per arch.
  • Adult teeth (Permanent Dentition): 32 teeth in total, erupt around age six.

Tooth Numbering Systems

  • Universal Numbering System: Used in the United States.
    • Starts at the upper right third molar (tooth #1) and goes to the upper left third molar (tooth #16), then jumps to the lower left third molar (tooth #17) ending at the lower right third molar (tooth #32).
  • Palmer Notation: Used in orthodontics and oral surgery.
    • Divides the mouth into four quadrants and numbers teeth 1-8 in each quadrant, using symbols to differentiate quadrants.
  • FDI (World Dental Federation) System: Used in most places worldwide.
    • Uses two digits: the first indicates the quadrant (1-4), and the second indicates the tooth (1-8).

Tooth Numbering for Primary Dentition

  • Universal System: Uses letters A-T instead of numbers.
  • Palmer System: Uses letters A-E with quadrant symbols.
  • FDI System: Uses quadrants 5-8 with numbers 1-5.

Tooth Surfaces

  • Facial Surface: The front of the tooth.
    • Anterior teeth = labial surface.
    • Posterior teeth = buccal surface.
  • Lingual Surface: The back of the tooth (closest to the tongue); can also be called the palatal surface in the upper arch.
  • Mesial Surface: Side of the tooth closest to the midline (middle of the mouth).
  • Distal Surface: Side of the tooth furthest from the midline.
  • Occlusal Surface: Chewing surface of posterior teeth.
  • Incisal Surface: Biting edge of anterior teeth.

Tooth Structure

  • Enamel: Hard, calcium-rich surface of the tooth; hardest tissue in the human body.
  • Dentin: Surface underneath the enamel that makes up the bulk of the tooth.
  • Pulp: Soft tissue inside the tooth containing blood vessels and nerves.
    • Pulp Chamber: Part in the crown.
    • Pulp Canal: Part in the root.
  • Gingiva: (Gums) Reddish-pink tissue that surrounds each tooth.
  • Alveolar Bone: Bone that houses and holds each tooth in place.
  • Cementum: Thin hard tissue that covers the root of each tooth.
  • Periodontal Ligament: Tissue between the cementum and alveolar bone.

Dental Diseases

  • Tooth Decay (Caries): Bacteria in the mouth produce acid from sugars, which melts away the mineral content of the tooth.
  • Gum Disease:
    *Plaque
    *collection of bacteria on the tooth surface.
    *Gingivitis
    *early form of gum disease/inflammation of the gums/reversible/red, swollen, bleeding gums.
    *Periodontitis
    * Severe infection of the gums and bone that supports the teeth/irreversible/bone loss/gums and bone recede away from the plaque.

Dental Treatment Terminology

  • Restoration: Treatment that repairs or replaces teeth (e.g., fillings, crowns, bridges).
    *Amalgam
    *dental filling material made up of a mixture of different metals.
    *Composite is a tooth filled material that is tooth color and is used to repair teeth or cosmetically enhance teeth.
    *Bonding is the process where the composite(tooth colored filling) is attached to the tooth.
    *Sealant thin plastic resin coating that is used on the back teeth to prevent caries from forming within the pits and fissures.
  • Crown: A filling that covers the entire natural crown when the tooth has broken down too much to be fixed with a smaller filling.
  • Bridge: A cemented appliance that replaces missing teeth by covering adjacent teeth and bridging the gap.
  • Denture: A removable appliance that replaces missing teeth.

Class Assignments

  • The first assignment is going to be an in-person HIPPA scenario. In this scenario, a patient has a meltdown during their office visit, and it will be your job to explain how you would handle it professionally.
    *The second assignment is going to be entering patient information into Dentrix. This will be optional to do the paper.
    *The third assignment consist of emailing to a patient letting them know that their preauthorization has been accepted.
    *Lastly, the group will have a coding assignment, bring the HSCPS book.
    Overall, the goal tomorrow is to provide quality customer service without jeopordizing.