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Managing Changes in Staff and Dental Insurance During COVID-19 [Podcast]

A Dentist’s Perspective on Embracing Changes
Young plant growing on stump

Dentistry is rapidly adapting how to manage dental insurance during the COVID-19 pandemic. Hear how one dentist in Iowa is adjusting the processes for day-to-day operations in her dental office. Guest Dr. Sara Stuefen shares what it’s like running a practice during unexpected circumstances—from hiring additional staff to verifying patient eligibility and negotiating fees with dental insurance companies to budgeting for personal protective equipment (PPE) costs.

This is episode 23 of Beyond the Mouth, a podcast series in which ADA’s Dr. Betsy Shapiro chats with a diverse group of people who can help with the non-clinical challenges dentists experience every day.

This episode was originally released on December 2, 2020.

Sara E. Stuefen, D.D.S., P.C.

ADA member dentist posing outside.

Dr. Sara Stuefen practices in Vinton, Iowa and is a 2010 graduate of the University Of Iowa College Of Dentistry. She devotes much of her free time to organized dentistry and is currently a speaker for the ADA success program. She recently served as a member of the ADA Council on Dental Benefit Programs, and District 10 representative for the ADA New Dentist Committee. She is past chair of the Iowa Dental Association New Dentist Committee and served on the IDA’s COVID-19 Return to Work Taskforce. Dr. Stuefen is an Associate Clinical Adjunct Professor in the Department of Family Dentistry at the University of Iowa and a Fellow in the International College of Dentists.

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Transcript

This transcript was edited for clarity.

Betsy Shapiro: Welcome to the American Dental Associations Practice podcast, Beyond The Mouth. Where we won't discuss clinical dentistry, but everything else is fair game. I'm Dr. Betsy Shapiro, a director with the Practice Institute of the ADA. In this episode, we're talking about managing a dental practice with a bit of a dental benefits perspective behind it. Joining me today is Dr. Sara Steufen from Vinton, Iowa, where she owns her own practice. She's very active in organized dentistry on all levels, most recently serving on the ADA's committee on the New Dentist, as a liaison to the Council on Dental Benefit Programs, and on her state associations Return to Work taskforce. Dr. Steufen is an associate clinical adjunct professor in the Department of Family Dentistry at the University of Iowa and a Fellow in the International College of Dentists. Hello, Dr. Steufen and welcome to the show.

Sara Steufen: Thanks for having me.

Betsy Shapiro: All right. So nice to meet you. I've heard so many good things about you, and I'm very excited for our conversation today to see what you're thinking, what you're doing, and what's happening in your practice. Can you start by telling us just a little bit about your journey to practice ownership?

Sara Steufen: Sure. So I graduated in 2010 from the University of Iowa, as you said, and I actually purchased my practice right when I graduated. So I jumped right in, I didn't have any family in dentistry, or family as business owners, but I went for it. And it was a small practice and we've been growing it over the past 10 years. It's been an adventure and this year has definitely been part of that.

Betsy Shapiro: So are you saying that COVID-19 impacted your practice just a little bit?

Sara Steufen: Absolutely. I can't imagine any dentist in the country, or the world that hasn't been impacted by COVID-19. Definitely not something that I expected coming into 2020, but it's our new reality.

Betsy Shapiro: I actually started in private practice right around the same time as the AIDS/HIV epidemic. And so my entry into practice was a little different as well, but not quite like COVID for sure. It was still an uncertain time. But I'm interested to hear your war stories. Can you talk a little bit about where you were at the beginning of 2020, and where you thought you might be by now, compared with where you actually are?

Sara Steufen: Sure. I kind of came into 2020 with the vision of where the year was going to go. Things were going well. I expected staff to stay the same. We had systems in place in our office that were working very well, that we had developed over the past 10 years and really honed in, and specialized is done and made things work really well to create a good experience for our patients.

And March 2020 came and we had to adapt and change everything. What we do now for checking in a patient and treating a patient is definitely changed, as it has for everyone.

Betsy Shapiro: We know, the whole world knows, that it has changed everyone's lives. And in particular, from our perspective, we see a lot of employees have lost their employment. They've maybe lost their benefits. Have you made any particular changes in your office with that thought in mind?

Sara Steufen: Yes. Employment has definitely been impacted by people across the country. What we've made sure to do is when we're talking about eligibility and verification of benefits for patients, it's really important that you're checking on that, and making sure that each patient is still eligible for their benefit. It's good to ask a patient if they've had any changes, either changes in their circumstances or their employment, so that you're verifying that.

I have a staff member who that's part of her daily duties is checking for future scheduled appointments, making sure that that our insurance information is accurate and making sure that that patient has a benefit. We're also making sure to document that. Because we know that unfortunately, sometimes employers aren't always communicating with the benefits company. If an employment status has changed, if their eligibility status has changed. And unfortunately, we find that out later. I've had that happen where it's maybe two, three years ago that you saw a patient. Now you're getting a notice from that benefit plan saying, we shouldn't have paid you. We want our money back. And now you have to collect that from that patient. So I've stressed how important that is with my staff that we're verifying that ahead of time.

Betsy Shapiro: If you have a staff person, whose part of their responsibilities is doing this for each patient you have coming in, is that something that was in their job description before? Did you get someone new? How did you handle this, because that's a huge chunk time.

Sara Steufen: Yes. Yes it is. It was part of her duties before, but we weren't checking it for every single appointment. We were checking it typically the beginning of the year, maybe halfway through the year, depending on the circumstances. But yeah, with her having to do that more, and our processes changing for checking in a patient, I did end up hiring another staff member to help us deal with all of these changes.

Betsy Shapiro: So hiring another staff member adds to your expenses and your overhead. What else have you noticed has changed with expenses and overhead in practice? How are you coping with that?

Sara Steufen: Well, one day at a time is how we're coping with that.

Betsy Shapiro: As are we all.

Sara Steufen: But definitely overhead has increased. We've been fortunate in the past to be able to have access to the PPE that we need, and knowing that you could probably get it shipped to you the next day. And now that's all changed. I work with my assistant. She does most of our ordering. And she has a budget she has to work with for the quarter. And this year it's just kind of been blown out of the water. Where we were before, maybe paying $7 for a box of gloves, and now we're paying $30, and we have no choice over what kind of gloves we just take whatever we can find. So that's been a major change.

Betsy Shapiro: Have you found any ways to mitigate that expense in any way with the PPE costs?

Sara Steufen: So we're still exploring the best way to do that. I think there's definitely been some support seen from dental benefits companies. Some have chosen to do kind of a reopening support payment. Others have chosen to reimburse for the code that we're using for PPE, which is D-1999.

So there are different avenues that have helped with that, but I think it's still kind of in flux what the long-term changes are going to be to deal with it.

Betsy Shapiro: You mentioned that there are some companies that have stepped up and helped out a little bit. Have you done any negotiating or anything like that with any of them? Or is that an option?

Sara Steufen: Yes. Negotiating is definitely an option. I have negotiated with some of the benefit companies that I'm in-network with in the past. I'm actually not due right now. So I haven't done anything recently, but I've done it two different ways. So I have negotiated and used a company who's helped me within negotiation and been the middleman to help me with that. And I've also done the negotiations myself.

Betsy Shapiro: Can I ask, successfully?

Sara Steufen: Yes. So I think negotiating is, to me a very intimidating thing. I'm not an aggressive person, but I think I would encourage other dentists that they can do it. I found that each benefit company is different. Some will allow you to renegotiate every year. Some are every two years. Some won't negotiate with you at all, but if you can find the provider relations manager for your area, and get in touch with them, they're typically used to the process I found that you have to sometimes wait. Sometimes they have 60 days to respond to you. So you have to be patient. They typically will get to you in that 60 days, but sometimes it's on day 60. So make sure you're keeping track of that. And I would say don't take the first option that they give you right away. Make sure to evaluate that. And look at your top procedures.

I think the first time I got a fee schedule back, they had really attractive fees for certain procedures that I maybe never do or do once a year. So it's really important that you're using your practice, natives, and software to evaluate what procedures are most important to you and what fees are most important for reimbursement.

Betsy Shapiro: I love that success story. So that's why I had to ask. That's great. Thank you. So Sara, in your practice, did you end up using telehealth services at all? And can you talk a little bit about that and how it worked out for you?

Sara Steufen: Yes. I did not do a lot, but I definitely did some. It opened my eyes to something that I didn't really expect to do, but it worked in this situation that we were given. I learned a lot from that. And I learned a lot about the processes with it too.

Betsy Shapiro: Was it difficult to learn the processes?

Sara Steufen: No. Everything has a learning curve. I think the ADA provided a really good document to help you work through what you need to expect, and what you need to think about as you're setting it up. At the time I use Zoom, and it was simple and easy to do with the patient. Just making sure that the patient is prepared for the procedure and how it's all going to work out.

Betsy Shapiro: I think the, perhaps silver lining out of COVID, is that we all find Zoom easy to use now, or fairly easy to use now. We were just forced into that world. Not that I'm endorsing any particular platform, it's just all of those. When you use Zoom, do you do anything in particular about patient privacy? Or how do you handle that?

Sara Steufen: So you want to make sure that the program that you're using is protecting the patient's health information. You don't want to use any sort of open faced communication, Facebook Messaging someone. Make sure that the patient is consenting to teledentistry.

Betsy Shapiro: And was billing fairly easy?

Sara Steufen: Yes. Billing is fairly easy. There are several teledentistry codes within the CDT that you need to be familiar with. And you need to understand the difference between synchronous and asynchronous teledentistry. Once you know that, then you are coding for the procedure you did. For example, a limited exam or a dental screening. And then you're adding in not code, whether it was a synchronous teledentistry encounter, or an asynchronous. So you're still coding for what you did. You're not removing that limited exam code. You're just adding in that teledentistry code.

Betsy Shapiro: What is the difference between synchronous and asynchronous?

Sara Steufen: So synchronous, this would be, for example, like what we're doing now, we're talking back and forth to each other. It's instant. I ask you a question, or you asked me a question, and I'm able to give you feedback right away. Asynchronous is where the data is collected, and then as a dentist, I'm looking at it later.

Betsy Shapiro: So that might be where I would leave a message for you or something with a picture and say, here's what's happening. And then you reply back later. Yes. You need to come into my office.

Sara Steufen: Yeah. Correct.

Betsy Shapiro: This is kind of interesting. I'm certain not what you pictured back in January.

Sara Steufen: Absolutely not, but we're all adaptable as 2020 has forced us to learn. Like I said before, I have systems and I have certain ways I want to do things. I know what works well for me, and we've had to find new ways to do it. But we're making it.

Betsy Shapiro: As we talk at the end of October in 2020, do you feel like you're settling, somewhat settling into a new normal that's comfortable?

Sara Steufen: Yes. Unfortunately it's taken, as we said, a lot more costs, new staff to make it work, and to make it the most comfortable for us within the office. But yes. I think we have gone from when we reopened back in May, to now where we don't have to think about each little thing, it's kind of built into us. It's part of our new muscle memory of how to get ready for a procedure. And it's not as big of a deal. We're able to do it, and we're able to keep going and keep working.

Betsy Shapiro: It's good to find comfort, isn't it?

Sara Steufen: Yes, it is. Yes, it is.

Betsy Shapiro: Is there anything else you'd like to share with us about what you perceive as either the changes, or how things are going, or advice that you might want to share with the world of our listeners?

Sara Steufen: Well, I think a couple of things, one being involved in organized dentistry, and having the ability to work with volunteers across the country and ADA staff. I think dentistry as a profession is in really good hands. I am so impressed every time I work with the volunteers, and the staff of what they are doing to advocate for dentists. And that definitely brings me comfort.

And then the other thing would be just taking care of yourself. I think, out of all this, we've been through a lot and our pictures of our mental mindset of where our career was going to be this year, and what dentistry look like has changed. And I know it's been really important to me to take some time for myself. And I think the same, I know for my staff, it's been important. So take care of them. My staff is absolutely amazing. They're such a good part of the team. And I think doing that has been so important to keeping us going and keeping us motivated.

Betsy Shapiro: Thank you again for joining us today, Sara. We so appreciate you sharing a snippet of your life and how it's changed. And we're glad to hear that you're getting back to a place of comfort, and that it's seemingly coming out on the other end okay. That's a message of hope for everyone. And thank you for sharing it.

Sara Steufen: Thank you so much for your time. Betsy Shapiro: If you have any questions for Dr. Steufen, you can visit her website at VintonIowaDental.com.

Betsy Shapiro: Now we're at the member question of the day. This is where we answer a question we've received from one of our members, and for this part of the show, I'd like to welcome Dennis McHugh. Dennis is the manager of third-party payer advocacy here at the ADA Practice Institute, and has been with us before on previous episodes. Hello, Dennis. And welcome back to the show.

Dennis McHugh: Hi Betsy. Thank you for having me.

Betsy Shapiro: So as you know, in the Practice Institute, we answer member questions every single day, and we wanted to share one that we've received with our listeners. I know you've heard this before, but here it is Dennis.

Dennis McHugh: Okay.

Betsy Shapiro: We took care of a patient in our office believing that we were not a network provider because we never signed an agreement with that plan. After it was all said and done and submitted to the third-party payer, we received the EOB statement, and we were paid as a participating provider. How did that happen? And is there anything I, or the ADA can do about this?

Dennis McHugh: Well that's a good question, Betsy. And that sounds like that's a transparency issue on behalf of the payer. So there are companies out there that are basically called PPO leasing companies. And what they do is they basically lease a network of dentists to either insurance companies or small regional third-party administrators, TPA as we call them. And what they do is those small companies don't really have a network. So they can lease a network from a company like a DentiMax, or Connection Dental, or Careington. Those are some of the big players. So the doctor would have signed a contract with the PPO leasing company, and then as a network with any number of different plans at that point. That's one way. The other way is that the doctor, in the contract they signed with one of the dental insurance companies, there may be a clause in that contract called an affiliated carriers clause.

And what that means is that the dental insurance company can lease your name to another dental insurance company. So once again, even though you did not sign a contract with that particular company, you may be in network because of the agreement you signed with a PPO leasing company, or because of the contract you signed with a dental insurance company that uses an affiliated carriers clause. Now the good news is that the ADA has been working closely with state dental societies to try to pass legislation to control the use of these agreements. And so at the ADA we've actually created what we call a model legislation for PPO leasing. And anyone at the State Dental Society can look at it. We kind of look at the laws that are out there, and we kind of cherry pick if you will, and put together clauses that we think would be best for your legislation.

Dennis McHugh: And generally the legislation addresses a couple of things. One of those things is that it gives you the opportunity as a dentist to opt out. So let's say the PPO leasing company leases you're name to accompany XYZ. And for some reason you don't like company XYZ. It gives you the option to opt out of being in-network with that particular plan. And the other thing with the network leasing laws is really transparency. The calls we've gotten from dentists a lot of times indicate that they were not aware that they were in-network with another plan, through the leasing agreement. The transparency portion of the law makes it, puts the onus on the insurance company or the leasing company to notify the dentist that they are indeed in-network with this new plan and the effective date. So that's, what's happening with the leasing of the PPO networks, Betsy.

Betsy Shapiro: Thanks Dennis. So to be proactive, I should look to see if there's an affiliated carrier clause when I'm signing contracts. And that way I'll know, or that's one way to know, I guess, if this is a possibility for me, right?

Dennis McHugh: Oh. Exactly. Yes.

Betsy Shapiro: And secondly, if it does happen, I can then look for an opportunity to opt out of that?

Dennis McHugh: Yes. Now some of the plans may not offer the opt out. But that's why I was talking about the legislation. If your state has passed legislation that allows you to opt out, then you can certainly choose that option.

Betsy Shapiro: Thank you, Dennis, for helping to answer that member question.