​​​​David Beber, DDS​

HMO Extras

Don't be shocked when I tell you that magicians really do not pull rabbits out of their hats. It is an illusion. The same goes for Dental Maintenance Organization care. How can the same dental procedure for which the dentist across the street charges $100 be performed on this side of the street for less than $50? It is not really possible without some “business sleight of hand”. There are lots of ways to make the DMO office profitable. The question is, “how do you make that work”? The answer is: you play by the rules. Every third party dental care delivery vehicle comes with a set of rules and it is not up to a provider to question them. Those are the rules, so we work within them.  The best way to make happy patients and still be profitable is to offer dental care that they want and that they don't mind paying for.  Thus, the additional adjunct procedures.  These are desireable procedures not covered by the patients' dental plan.  And, although patients do not like utilization management, it is often necessary.

 

Periodontal Scaling and Root Planing

The first bit of “Maintenance Magic” begins in the hygiene department. What starts out as a simple prophylaxis often becomes a "scaling and root planing" (CDT Code 4341). It is a legitimate and often necessary dental treatment, although covered by dental insurance. The question is: “When does a patient need it”? Deep cleanings, as they are called, are needed when calculus exists beneath the gum line in the presence of excessive pockets and inflammation. Since the calculus is not always visible on an x-ray image, we have to look at other signs like pocket depth and bleeding caused by inflammation for the diagnosis.

For a proper diagnosis, before initiating deep cleanings, a thorough periodontal probing should be done. Generally speaking, pockets of 4 - 5 millimeters or more with bleeding (inflammation) and calculus are not only indicators for a deep cleaning but also for a site specific antimicrobial agent which is usually not a covered benefit. Most patients do not care about their periodontal probing chart and although periodontal charting is somewhat subjective at best, insurance plans require the chart to justify the 4341 procedure. Also, most gums bleed when probed. So, a case can be easily made for the scaling and root planing.  Dental offices with HMO / DMO patients can't afford to give away too many cleanings, so ways have to be found to generate better fees through the offering of Optimal Care.  They and their patients would be well served by promoting the use of anti-microbial agents like Arestin (CDT code D4381) as part of a continuing care program.

 

Crowns

Crowns are a common dental service. Crowns restore teeth that are too badly damaged for a filling to adequately repair. When a tooth is damaged or previously filled to more than 50% of its original structure, a crown is usually warranted. Since fillings generate extremely low fees in an HMO / DMO plan, the dentist may be discouraged from doing them even if they would adequately restore a damaged tooth. Crowns generate a much higher fee, and it's easier to add on "extras" to a crown procedure.  The DMO plan patient is only offered the SSC (Stainless Steel Crown) but would be better served with an all ceramic crown like the Lava™ Crown (CDT code D2740).  And they do not mind paying for it.

 

Surgical Extractions

This is another perfectly common service. Sometimes teeth are beyond repair and need to be removed. There are routine (non-surgical) extractions, and there are surgical extractions. A surgical extraction means that incisions were required or the tooth had to be taken out in multiple pieces. Again, this is a legitimate and sometimes necessary approach. In an HMO / DMO plan, routine extractions generate a very low and unprofitable fee. So, it is common that a "surgical extraction" is diagnosed in an effort to eek out some profit for the service. In the HMO office, most extractions are diagnosed as "surgical extractions." Surgical extraction can be a safer way of removing a tooth and can preserve bone or at least be performed more quickly to benefit the patient.  But the real benefit to the patient is the "Bone Replacement Graft For Ridge Preservation" (CDT code D7953), another non-covered procedure.

 

Local Anesthesia

The HMO / DMO office needs to charge separately for Buffered local anesthesia. It is another way to add another $20, or so, of profit. This charge should be added onto any service that requires a local anesthetic. Most patients expect that their dental plan does cover local anesthetics.  And, the American Dental Association's Current Dental Terminology (CDT) specifically stipulates local anesthesia is not a separate treatment code.  However, it might be justified during the course of routine treatment if the benefits of buffered anesthetic is presented to patients.

 

Filling “Add Ons”

Fillings are a very common dental service. The HMO / DMO dental plan booklet lists fees that are substantially lower than the regular dental office filling fees; however, the HMO / DMO dental office can't afford to provide the service at less than 50% of the typical fee. So, they must find ways to increase the fee with "non-covered" services such as: bonding, pulp caps, occlusal adjustments, anesthesia, and more.  The better choice here would be to recommend a better, though "uncovered" service, the all ceramic Lava™ Inlay or Onlay (CDT code D2620 or D2642).  The all ceramic inlay has benefits for them that most patients appreciate.

One of these is a legitimate additional billable service - a pulp cap. Although pulp caps are rarely done, pulp cap is usually indicated when a cavity is so deep it nearly reaches the pulp of the tooth and is on the border of needing root canal treatment. The HMO / DMO office should routinely place pulp caps to protect the pulp and to generate more fees. Although diagnosing “Add ons” like bonding, bite adjustments, and anesthesia are considered steps in the placement of every filling, they can often be “unbundled” to make them billable separate procedures.

In-House Specialists

Specialists are a very important part of dental care. Most dentists refer patients to specialists often when their needs are beyond their abilities. Having in-house specialists is not wrong in any way and is convenient for the patients. Specialists should be brought "in-house" at HMO / DMO oriented practices to help the bottom line.

General dentists are qualified to provide "specialty" treatment such as root canals and extractions, for example. It is up to the general dentist to decide when a particular case is within his or her comfort zone or abilities. If a particular case is too difficult, the general dentist should refer to the specialist. However, if the case is straightforward, there's no reason that a general dentist can't provide the service.

When the contracted fees for a root canal or extraction, if done by a GENERAL DENTIST, is very low - too low to be profitable, and there are not many "extras" that can be added on to an extraction or root canal, a specialist can return the case to profitability. There is a loophole with these plans.

A specialist can charge the "normal fee minus 25%." So, we get around the dismally low fee that would be paid to a general dentist by hiring a specialist to do ALL OF THEM - even the less complex cases that could be done by a general dentist.

 

Loose Dentures

Patients with loose dentures, especially the lower one, are looking for a solution to this problem.  The Small Diameter Implant (SDI) or Mini Dental Implant (MDI) is their solution (CDT code D6013).  These work great and patients are happy to pay for this service.  Of course, many of the dentures that patients are using are not adequate to accommodate the internal retaining housings that secure the implant heads and, so, a new denture must be made.  Another service that these patients like is the Interim Denture (CDT code D5810).

 

Off-Shore Dental Laboratories

Like many industries, dental lab work (crowns, bridges, dentures) is increasingly being out-sourced to third-world countries. The advantage, of course, is that cheap labor allows for very low lab fees. This creates a significant savings to HMO / DMO providers looking to cut costs. Most of the off-shore labs use the same equipment and materials that are used in the USA.  However, having said that, most established, local labs can offer fee reductions for clients who send all of their lab cases to them.

 

Crown Extras

This is where the HMO / DMO provider can get really creative. The plan guide may say a crown should be $600, for example. That's typically less than half of what the private dentists charge. But, the fee can be adjusted quite a bit.

The HMO / DMO office can add on a comprehensive list of non-covered charges such as: precious metal, desensitizing, occlusal adjustments, local anesthesia, cord packing, temporary crown, porcelain, and more. This is "unbundling." Although these items are usually not separate procedures, they can be charged for separately through the “unbundling” process. By the time we get to the bottom of the "extras" list a crown fee may be double the fee listed in a plan guide.

 

The Tip of The “Iceberg”

There are many more ways to increase revenues under a DMO program. For instance, take the simple PFM crown, CDT code 02751. This procedure has a name and a code which locks the provider into a revenue corner. But, some dental offices offer a diagnosis of a “Cerec”, which can work better. It has no code and is not found on the plan schedule. It also has other patient benefits like one visit service, better cosmetics, no temporary crown needed and fewer shots.

Another great service, appreciated by patients is the Porcelain Laminate Veneer (CDT code D2962).  The veneer is not a covered benefit yet patients are happy to pay for it because they want it to fix their cosmetic issues.

I have seen a list of alternative procedure names, all of which are designed to help profitize the HMO provider.