The Four-Headed Monster

A Blog Post from Dr. Steve Wolff

Dr. Charles Blair told us this day was coming. The demise of indemnity insurance and the proliferation of the PPO model has changed several aspects of the dental practice and industry. While a few offices (especially in rural areas) can operate without participating in an ever widening umbrella of preferred provider organizations, the fact is that most practices are affected in several ways, some of which they have not yet realized.

The first and most obvious is the downward trend in reimbursement. Most providers quickly realize that they are getting paid less for any given procedure than they were in the recent past. As third party payers (for better or worse let’s lump them together as “insurance companies”) negotiate deals with employers or institutions over the amount of benefit they will pay based on a set premium dollar, the provider of those services is generally not invited to the table. Consequently, since the buyer always wants to pay less and the payor always wants to provide a more attractive package of benefits, the provider becomes the shock absorber that balances the equation. Without benefit of representation, you now receive $69.00 compensation for a procedure for which you used to receive $105.00.

The next issue to rear its ugly head is the need for ongoing “Credentialing”. In spite of the generally good track record Dentistry has amassed over the last several generations, dental offices are now expected to participate in a location specific, ongoing paper chase to presumably assure the payors and consumers that they are being treated by the purest and most chaste of hands. Since there is no universal credentialing (like maybe a license issued by a state board or some evidence of ongoing education?) this process must be repeated ad nauseum with every company even remotely related to a claim for payment of services. Once again, the provider has no voice in this process and must endure the cost and time commitment to be in compliance.

Here’s one I’ll bet you hadn’t thought of:  the chance of getting a colleague or a locum tenens doc to come into your office in the event of an emergency in order to keep the doors open is becoming a distant memory. Notice in the previous paragraph I referenced the “location specific” paper chase. The fact is that if you provide services in an office, you must be credentialed in that specific office in order for the practice to bill and receive payment “In Network”. Since by definition an emergency demands immediate action, the realization that credentialing will require weeks if not months to accomplish will certainly make it difficult for patients to be seen and staff to be paid.  And don’t even think about billing the work under the host doctor’s name – as that is seen as out and out insurance fraud, the penalties for which can be catastrophic. Years ago I participated in a mutual aid society made up of nine docs who agreed that if any one of us went down the other eight would work half of a day in the office to keep things running. The lack of portability of credentialing now makes those arrangements difficult if not impossible.

Lastly is the wa-wa that most directly affects our business. That lack of portability that makes locum tenens work difficult also makes a practice transition a little more painful. Now after a seller accepts a buyer’s offer, one of our first steps is to begin the credentialing process. The hope is that when the buyer takes over their new practice, they can be paid for their work. Since this process can take so long (months), we can find ourselves in limbo as the buyer has to titrate between their desire to get started in their new office and timely payments for service. While in the recent past we worked on a 45-60 window to closing, that date can now be hard to pin down.

So we’ve pointed out the problems and whined about them a bit, what do we do next? Unfortunately there does not seem to be much the individual doc can do. They just don’t have enough horsepower. Sure they could stop participating in PPOs but the realities of business and cash flow make that a hard choice for most practices. It would seem to me that legislation is going to be in order and the first step in getting things under control might be to leverage the emergency coverage issue. Who wants to bear responsibility for letting patients be left stranded in the middle of care?  Standardizing the requirements and allowing a doctor’s license and credentials to follow them would be a start. Working under the host doctor’s (or their estate’s) supervision would seem temporary fix.

While that legislation might not correct all of the problems, at least it would give the providers a seat at the table in the ongoing discussion. Keep this in mind however: in my children’s lifetime, a single payor system of payment (read Uncle Sam) will be in place for all health care needs. Plan accordingly.

Dr. Steve Wolff – UMKC Class of 1977