Do you think your insurance company has your health in mind? I didn’t think so. This hasn’t always been the case with insurance companies, nor do I think it’s always true today; it certainly does seem to be the trend, however. One night, I watched an episode of 60 Minutes with Scott Pele, which illustrated how the case review process used by insurance companies is often a barrier to proper patient care. (Click here to see the episode.) This story used the medical insurance industry as an example but I have found the same to be true with the dental insurance industry.
When we go to the doctor to be diagnosed and treated for an ailment—whether it be a medical or a dental problem—we assume the doctor we are seeing is making the decisions about how to diagnose and treat. I wish this were true! In reality what sometimes happens is a third-party reviewer—a doctor hired by the insurance company—reviews the case and either accepts or denies the claim made by the doctor actually caring for the patient. The third-party reviewer never sees or touches the patient and in some cases is making life or death decisions about the patient’s treatment. I’m not saying there shouldn’t be a review process to weed out fraudulent or unnecessary treatment. But there definitely shouldn’t be a financial incentive for the reviewing doctor to deny claims. In one case, 60 Minutes investigators found that one reviewing doctor had a ninety-one percent denial rate on claims and was making over $20,000 a month just on denials alone.
Something is wrong with this system. The business model for insurance companies is focused on profit while the business model health care providers should be—and usually are—focused on providing the best possible care to help patients get better. Those two business models are at war with one and other. “Managed care” has become more like “Managed Expense.” This is wrong, and why I’ve focused my dental practice on care, not on being a “preferred provider” for innumerable insurance companies.