Collecting Payment Out of Network

How do you collect payment when you are out of network, and the company prohibits patients from assigning benefits to the practice?

What are the patient’s payment options?  Can the patient use HSA/FSA? 

The answer is that the patient can use HSA/FSA to pay the practice in full and then reimburse their HSA/FSA when the insurance reimbursement check is received.

According to the IRS website:  “If amounts were distributed during the year from an HSA because of a mistake of fact due to reasonable cause, the account beneficiary may repay the mistaken distribution no later than the due date of the tax return (not counting extensions) following the first year the account beneficiary knew or should have known the distribution was a mistake.”  

This rule covers the scenario where a patient charges 100% of the dental treatment fee to their HSA/FSA because the exact insurance reimbursement amount is unknown at the time of treatment, and the insurance company subsequently sends the patient a check for partial reimbursement.  The IRS has a form for this purpose.

It would be easier for the patient to put the full treatment amount on their credit card and subsequently get reimbursed to the extent allowed by the insurance company. 

There is another very good option.  According to CareCredit®, if the practice is out of network with the patient’s dental insurance carrier, the patient can charge the full amount of the fee to CareCredit®. When the patient receives partial reimbursement from the insurance company, the patient has the option of putting those funds toward early repayment of the CareCredit® balance.  

The patient is not obligated to use those funds to accelerate CareCredit®repayment, of course.  The patient only needs to pay off their CareCredit® balance within the prescribed interest free period to avoid interest charges.

By being aware of these payment options, practices can be best prepared when dealing with out-of-network insurance questions.

Dental Hygiene Visit: It’s Not Just a Cleaning.

A dental hygiene visit in our office is not just a cleaning.  It’s an important health visit with many important benefits to you:

  1. Think of a hygiene visit as the cheapest form of dental insurance.  The best way to protect your oral health and avoid major dental problems in the future is to have regular check-ups, including hygiene visits. 
  2. Hygiene visits help protect your investment in dental treatment.  Keep up with your dental hygiene appointments to get the most out of the dental care you have received.
  3. Losing teeth is not a natural part of the aging process.  With proper care, you can keep your teeth indefinitely, even a lifetime. 
  4. Periodontal (gum) disease is often a “silent disease.”  Just as many people are unaware that they have high blood pressure, gum disease often does not have noticeable symptoms until it reaches an advanced stage.  Dental hygiene visits help keep your gums healthy.
  5. Oral health is part of overall health.  There is an increasing body of knowledge showing relationships between good oral health and overall health.  For example, gum disease may make it harder for patients to control diabetes.  While more research is needed, gum disease has also been associated with other systemic diseases.  Our motto is, “healthy mouth/healthy body.”

Enjoy the fresh and clean feeling in your mouth after a dental hygiene visit, but remember, it’s so much more than a cleaning.  

Recognizing a Major Patient Education Problem–Illiteracy

According to the U.S. Department of Education, 54% of U.S. adults 16-74 years old–about 130 million people–lack proficiency in literacy.  These individuals have a reading aptitude below the sixth-grade level.

There are numerous reasons for this shocking statistic: poor education, learning difficulties, learning English as a second language, or simply lack of exposure to English.  These issues are apparent across many demographics and may affect even high achievers.  For example, an adult literacy program reported that one student was a well-respected cardiologist in his home country, but when he came to the United States mid-career, he was not able to read and write English.

There are four learning styles:

  • Auditory (listening)
  • Reading (comprehending written materials)
  • Visual (seeing)
  • Hands-on (kinesthetic or learning by doing)

For individuals who do not have a good command of English, verbal explanations may not be clearly understood.  Those with underdeveloped reading skills may have difficulty reading printed instructions or patient education information on a website.

This problem is compounded because it is not uncommon for people to be embarrassed by their lack of reading ability.  Stories abound of adults hiding their illiteracy or procrastinating for years before enrolling in a reading program, which are often taught be volunteer tutors.  There are patients in your office every week who sign forms and appear to understand spoken and written instructions but who do not fully understand the messages you are conveying.

For these patients, visual representations such as photos (intraoral and extraoral), x-rays, and videos are very useful.  Allowing a patient to handle a model also helps them understand the treatment plan. 

Dropping Insurance Plans: The Agony and the Ecstasy

There is an old joke among entrepreneurs: “I lose money on every transaction, but I make it up in volume.” There are times when this principle applies to dental insurance reimbursement.  The insurance companies are actually making it easier for dentists to decide to drop insurance plans because reimbursement rates are low, especially in light of cumulative double-digit inflation over the last two years, which makes the cost of delivering services higher than ever.  You can only discount fees so much before profits turn to losses.

In spite of these economic realities, however, there are other considerations.  I listen to many recorded calls to dental practices (with the appropriate HIPAA announcement that calls are recorded for training and quality assurance.)  The most common opening question from prospective patients is, “Do you accept the XYZ insurance plan?”  If the answer is “No, we are not in network with that plan,” the phone call often ends abruptly.  It’s an insurance hang up, in more ways than one.

If you want to get off of insurance plans, do the following:

  1. Build up your fee-for-service practice.  If you truly want to have a niche practice, focused on quality and not beholden to insurance companies, then you need to create that successful brand before you start culling the herd.   Two ways of accomplishing this goal are by offering a strong mix of profitable services and encouraging your uninsured patients to refer their family and friends.
  2. Start by eliminating the plan that affects that fewest patients and provides the least reimbursement.  Assess the impact on your practice before dropping other plans.
  3. Provide sufficient lead time for the transition.  I do not recommend sending a letter to large numbers of patients telling them that you no longer accept their plan.  Instead, inform patients verbally and in writing as they come in for appointments that at a time certain in the future, the change will be made.  As new patients call, of course, they should also receive this information.  
  4. Train the team.  Using the right verbal skills is essential.  You want to be clear and confident with patients, not apologetic.  You are making the change to maintain high standards, which in itself is a benefit to patients.

There is a certain amount of agony and soul searching that goes into the decision to drop insurance plans, but the payoff is sheer delight—the ecstasy of not having fees dictated by a third party.  Some dentists have handled the transition poorly and harmed their practices; but, when done, correctly, the decision is liberating.  Dentists who have been fee for service for several years would never go back to the old way of doing business.

One caveat:  The process is fraught with landmines.  If you would like to have a complimentary conversation with me about this topic, feel free to contact me.

David Schwab, Ph.D. is a practice management consultant, coach, mentor, and seminar speaker.  Contact: (407) 324-1333.

(This article first appeared in the Collier& Associates newsletter and is reproduced with permission.  I highly recommend this financial and business newsletter.  For more information, click here):

No More Deer in the Headlights:  Speaking Confidently About Fees Chairside

Most dental team training programs have a glaring omission: clinical team members are often not trained to answer patients’ questions regarding fees.  Administrative team members at the front deal with these questions every day, and many are quite adept at explaining value for the dollar with regard to proposed treatment.  However, when patients turn to an assistant or a hygienist chairside and express concern about dental fees, the clinical staff are often unprepared.

It is common for back-office team members to be uncomfortable with these types of questions.  They may respond by saying, “You have to speak to someone up front about that,” which is a true statement except that it is often conveyed in a halting tone that betrays a lack of confidence.  The effect that financial questions have on assistants and hygienists is similar to Superman being exposed to kryptonite.  Over the years, the super-human caped crusader was unstoppable—until he was exposed to material from Krypton, his home planet.  Back-office team members should not lose their superpowers when a patient asks why a procedure seems so expensive.

Here are three very good answers when patients ask about fees chairside.  My comments are in italics.

  1.  Our fees reflect the quality of care provided uniquely to you. Dr. Smile uses only the best materials and technology.  This statement brims with confidence and reinforces value for the dollar. 
  2. It’s a great investment in your health.  You deserve it.  Patients need to hear again from their trusted assistant or hygienist that the proposed treatment is in their best interest.
  3. Patients tell us all the time that they wish they had decided sooner to have the treatment.  Let’s go to the front and you can speak to Julie about different financial options.  This transition is seamless and can be used with any of these answers.

Clinical team members are not expected to make financial arrangements or discuss fees in depth with patients.  However, their verbal responses to patients’ questions about fees and body language are very important.  The deer-in-the-headlights look is an expression of anxiety.    When all dental team members are properly trained to handle the money question and respond succinctly with rock-solid confidence, patients feel more comfortable moving forward with recommended treatment.  Practices owe it to the team and the patients to provide such training.

Free Dental Practice Management Webinar for Specialists/Residents

Click to register:

January 22, 2022 11:00 a.m. Eastern. David Schwab, Ph.D. presents: “The Future Isn’t What it Used to Be.” Offered by the International Association of Dental Specialists (iADS), this one-hour dental practice management webinar is free to dental specialists and residents. Future courses in the Business of Dentistry Series require iADS membership. Residents pay only $10 per year! See the registration link above.

Dental Disruptions: New Course

Here’s a very timely new dental practice management course. Attention Meeting Planners: This course is available for you to schedule for your dental organization. It’s designed for dentists and dental teams.

Dental Disruptions Course Description: The dental practice environment has changed more in the last five years than in the previous twenty years.  Solo practices in particular are facing overhead and staffing challenges; more group practices are emerging; and DSO’s are offering opportunities and challenges.  At the same time, technology is revolutionizing not only clinical dentistry but also the business side.  

This course teaches dental professionals how to stay ahead of the curve, find the best practice model to suit individual needs, and use technology wisely while retaining the personal touch with patients.  This very timely course shows practices how changes in dentistry can liberate dentists and team members from routine tasks and also allow them to take advantage of high-tech, cost-effective target marketing.

To learn more and schedule: contact

Dental Practices Need to Raise Fees To Keep Up With Inflation

The Consumer Price Index went up 5.4% in July, the largest jump in 13 years. In addition, according to Moody’s Analytics, the U.S. is experiencing “the strongest wage growth in a quarter century.”

Inflation is overhead on steroids. Dental staff salaries and benefits are the largest overhead line items in dental practices.

It’s time to analyze the numbers in your dental practice and raise fees. You want to be fair to your patients, of course, and large increases for fee-for-service patients can lead to pushback. The goal is to proceed methodically, raise some fees more than others; but make sure that the average increase keeps the overhead monster from eating into your profits. 

You cannot afford to “hold the line” on fee increases when your suppliers and your staff are demanding more from you. I’ve been going over numbers with my dental clients and making recommendations. Plan now and put a new fee schedule in place no later than January.

Linda Harvey Interview

David: This is David Schwab. And today I’m really excited because my guest is Linda Harvey, a nationally recognized healthcare risk management and compliance expert who helps dentists and teams understand and navigate regulatory requirements. She is the founder and president of the Dental Compliance Institute, as well as a compliance consulting firm. Her career in dentistry began as a dental hygienist. Since that time, she has worked in corporate risk management and has been recognized as a distinguished fellow in the American society of Healthcare Risk Management. In addition, she was honored to consult with the ADA on three separate occasions regarding compliance.

Linda, welcome to the program.

Linda: Thank you, David. It’s a pleasure to be here.

David: First of all, how did COVID impact your business last year?

Linda: Well, David to say that it was insane would be an understatement with the constant flow of new information that we were trying to learn.  As a consultant and coach for doctors and teams around the country, we were trying to stay one step ahead of all the new, late-breaking information. So we ended up coaching doctors remotely across the country, as well as our local clients. And we participated in a number of different social media events and interviews. So, we can help bring that voice of reason and help everyone be calm and understand the requirements so they could sort of settle into those massive changes that we all had to make so quickly.

David: Yes, I can imagine. The regulatory work that you do is so important, but once COVID hit, it must have just added a tremendous number of new questions and people needing help.

Linda:  Absolutely. There were questions from everywhere. We began questioning how or why we’d always done something in the past. You know, we weren’t sure if we were handling the possibility of transmission in our practices appropriately and how much should we do and how much was overkill and what was actually regulatory required and what was, you know, something that we were doing to make us feel good and it really wasn’t effective at all. So we were really working hard to get accurate information out.

David: Now that more people are getting vaccinated, do you see things settling down this year?

Linda: David, I have to tell you the short answer is absolutely no. We now are in a better position because we have a year’s worth of understanding of COVID and variants in order to help protect different populations, patients, as well as workers.  The regulatory changes are going to keep coming. For example, OSHA launched a new national emphasis program about a month ago, and this was related to worker safety in all industries and their protection against COVID-19. So when this launched, when you read the background on this information, this actually came from the presidential executive order back in January, trying to make sure that all workers in all industries were safe, have protection against COVID-19. So, we’re going to see some inspections being carried out by OSHA, both onsite and remote. And those inspections will include dentistry. They’re going to be looking first at those industries and organizations that had high rates of employees contracting COVID at work, because OSHA is concerned about on-the -job illnesses and injuries.  And we know that dentistry was placed in that high-risk category because of the aerosols that are produced.  OSHA we’ll also offer training and outreach. So I highly recommend that any of our listeners, if they see or hear about any OSHA outreach training in their area, please be sure to attend it.

David: Linda, do you foresee any other compliance issues on the horizon?

Linda: Yes, we have a lot of things going on. There are several other compliance changes on the horizon. In addition to OSHA’s national emphasis program that was launched last month, that’s going to include both remote and onsite inspections, OSHA will be offering training and outreach programs. I highly recommend that you keep your eyes open for those trainings so that our listeners can actually hear and meet with representatives of OSHA firsthand. In addition, we’re seeing a couple of changes on the HIPAA side of the house, so to speak.  In January, the HIPAA Safe Harbor bill passed. And now there are also proposed changes to the privacy role, and I’ve been trying to immerse myself in that. Absolutely, a lot of changes going to happen. For example, the privacy rule has always been about patients’ rights to access their information and how we have to protect their information within our practices, but this new section, that’s going to be global.

It’s going to be passed. I mean, it is still under that rulemaking process, but the recommended rules and proposal changes are going to significantly modify the provision of the individual’s rights to access their protected health information. And one of these big things that I’m struggling with here now, they’ve been trying to understand is that in doing so, it’s going to strengthen the patient’s rights to inspect their protected health information, both in person, which is going to allow the patients to take notes or use other personal resources to view and capture images of their PHI–protected health information. This is going to be an eye-opener when we think about how this can impact the practice. I’m curious to follow this more closely during the public comment period for about another month and see what kind of feedback comes and how that’s going to be interpreted by the regulatory bodies.

David: Linda, I’m sure many doctors feel that this could be just overwhelming, and we don’t want that to happen. So what’s your advice for offices so that they can stay current and prepare for these changes?

Linda: You’re absolutely right, David.  This can seem awfully overwhelming, and we need to approach it in that calm level-headed fashion. So, we’ve identified three ways that offices can kind of get their arms around this. First, start off by reading your current policies and procedures, know what you have in place, so you can begin to identify gap where you would need to make changes as these rules get rolled up next. 

Second, be sure you’re relying upon qualified experts for advice or assistance. You know, in other words, always question why, but question in a good way, not in a resistance way, but in a way that’s going to open yourself and your team up to learning, you know, are you actually doing the process properly? Is that actually the way you should be releasing records? Is that actually the way you should be cleaning and disinfecting an operatory?  Sometimes we add in extra steps and do other things, regardless of what regulation we’re talking about. And before we know it, we’re really not in compliance. 

And third, I invite our listeners to join us at the Dental Compliance Institute for that extra compliance edge, or better yet sign up for one of our courses or our Inspection Ready Series. That’s our new IRS, David, and that’s those workshops. And the IRS workshops are where we take a deep dive into one of those particular standards. It’s such a great feeling when a practice can go from being confused or crazed to confident competence.

David: Linda, it’s a brave new world. We always needed you for so many things like HIPAA, but now with all of the new regulations, new laws and everything that the pandemic has caused to come into practices, we need you more now than ever before. Thanks so much for speaking with us today. You’re doing great work in the world.

Linda:  Thank you for having me, David. It’s been a pleasure.


Dental Practice Transition Psychology: Part 1

Welcome to the first part of my three-part series on the psychology of practice transition.  I’ll be talking about how to get an associate into a practice with the goal that they will buy the practice.

Today, let’s discuss today the selling doctor’s concerns. If you’re the selling doctor, one of your big concerns is, “I don’t want to make a mistake. I want to find someone who’s the right fit.”  I will tell you, trust your instincts. Don’t ignore any red flags. No, nobody’s perfect, but if something’s nagging at you, if you’re not sleeping at night, if you’re worried that maybe you’re not making the right decision, don’t do the deal. You absolutely want to make sure you find the right person. Don’t settle.  You don’t have to sell to this person. They’ll always be another seller who comes along.

How do you determine if something is a good fit, if it’s going to work out, if

this person really is going to be compatible with you and share your values?

I like to use scenarios, hypothetical situations. I give both the associate and the seller a scenario. Maybe it involves, “How would you deal with this situation as it relates to a patient?” Or, “How would you deal with this other situation as it relates to a member of the staff?” They work on these scenarios independently. Then we come together by phone, by Zoom, and sometimes in person, and we discuss.

You learn so much: you learn how people think, you learn how they prioritize.

You learn how they process information, and, most importantly, you learn about their values–by using these scenarios, these hypothetical situations. It’s so important because you gain many valuable psychological insights and that helps you make the right decision.

I enjoy using these scenarios and being the facilitator to make this work out. 

In the second part of my three-part series, I’m going to discuss the concerns facing the associate.