Lie #2: I Need a Preauthorization

This post is our second post in the Biggest Lies in Dentistry Series. Things the dental industry repeats to itself until they sound true. See the full series here.

Predetermination. Preauthorization. Different names. Same misunderstanding.

What It Means in Medicine

Patients are used to medical insurance, which works very differently from dental insurance. In many medical plans, you have a primary care physician, and there are rules you must follow before seeing certain specialists or having procedures performed. One of those rules may be obtaining preauthorization. In that setting, the word means exactly what it sounds like. The insurance company is authorizing the service before it agrees to pay for it.

That is not what preauthorization means in PPO dentistry.

What It Means in Dentistry

A dental preauthorization does not authorize the doctor to perform treatment. It does not even guarantee payment. In fact, it says right on the form that it is not a guarantee of payment, which makes the term “preauthorization” in my opinion rather ambitious.

What it provides is another explanation of the patient’s dental benefits. If you submit for a crown, the response may tell you that crowns are covered at 50 percent, that the negotiated fee is $800, that the plan expects to pay $400 and that the patient’s estimated portion is $400. That’s useful information, but it is not an authorization. It is benefit information.

You Already Have This Information

The obvious question is why the office needs to request that information…again.

The patient’s benefits should have been verified before the patient arrived. The office should already know what is covered, what is excluded, the applicable percentage, the deductible, the remaining annual maximum and the estimated patient portion. That information should have been obtained online or, when the online information was incomplete, by calling the insurance company. If the office already has the benefits, sending a preauthorization is essentially asking the same question twice and waiting two weeks for the second answer.

Why Offices Keep Doing It Anyway

There are several reasons offices continue doing it. Sometimes the patient asks because they believe dental preauthorization works like medical preauthorization and that treatment cannot begin without it. Sometimes the office believes the same thing. “We have always done it this way” has created a remarkable number of dental policies that nobody can explain.

Now, I’m not privy to insurance company policies. But it appears that insurance companies encourage preauthorizations, and frankly, again, in my opinion, that makes perfect business sense for them. Insurance companies collect premiums and pay claims. Every business tries to control expenses, and insurance companies are no different.

Maybe Delay Is the Point

Every good business owner also knows that the longer it takes to close a sale, the less likely the sale is to happen.

You present treatment today while the patient understands the problem and is motivated to fix it. Then you tell them you will submit a preauthorization and call them when it is returned. Two weeks later, life happened. Their car needs repairs, there is something else they’d like to buy or some other expensive issue came up in their life. The tooth that mattered two weeks ago has been demoted by the household budget. Adding time to a decision reduces the chance that treatment will be completed. Again, I don’t have insight into their company policies, but it would be rather surprising to me at least, if carriers did not encourage the delay.

When It Is Not Really About the Preauthorization

Sometimes, however, the preauthorization is not really the problem. The patient may say, “Let’s submit it first,” in the same way another patient says, “I need to think about it,” “I need to speak with my spouse,” or the ever-popular, “I’ll call you.” In that case, the patient has not yet decided to proceed. Sending a preauthorization does not fix that. It simply gives the patient a more official-sounding way to leave.

That is a sales and education problem. The patient needs to understand what treatment is required, why it is necessary, what will happen if it is delayed and what they gain by completing it. Better communication fixes that problem. More paperwork never has.

One Exception Worth Knowing

I am specifically addressing PPO plans here. HMO dental plans are different and may genuinely require authorization before certain treatment. In all the years I have worked with PPOs, I have personally never encountered a PPO contract that required preauthorization before treatment. That does not mean one could not exist. It means that if you want to know what your plan requires, obtain your contract from the insurance company and read the damn thing! Do not build an office policy around something a carrier representative may have said on the phone three years ago.

What to Say Instead

When a patient sincerely believes a preauthorization is necessary, explain it clearly:

“Let me explain what a dental preauthorization is and why we do not routinely delay treatment for one. It is not an authorization to perform the dentistry, and it is not a guarantee that the insurance company will pay. It is another explanation of what your policy covers.”

Give them a moment, then continue.

“We have already verified your benefits, so we know what the plan is expected to contribute and what your estimated portion will be. No one can guarantee payment until the claim is processed, but the treatment is covered under the information provided to us, and we will work to ensure the company pays everything it is supposed to pay under your plan.”

Then return to the reason the patient is sitting in your office.

“More importantly, you need the treatment. Let’s talk about what needs to be done in your mouth, why it matters and what your goals are. Once we agree on the right treatment, we will do our best to maximize every dollar of your dental benefit and figure out the most comfortable way to make the rest affordable.”

When Instant Predetermination Helps

Some carriers now offer instant online predeterminations. If you can obtain one in seconds while the patient is still sitting in front of you, and it helps the patient move forward without introducing delay, use it. Just explain that it still is not a guarantee of payment. Plenty of treatment has been “preauthorized” and later denied, which tends to make everyone suddenly discover what the fine print meant.

Two Different Conversations

Never confuse benefit verification with treatment acceptance. One tells you what the benefit company is expected to contribute. The other helps the patient understand why they need treatment. Those are two completely different conversations.

The patient’s health is always more important than what the plan will contribute. If your practice truly believes that, your patients eventually will too.

Part of The Biggest Lies in Dentistry. Read the full series here.

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