Today, Dr. Willey is the most successful stand-alone sleep practice in the United States.
It isn’t always pleasant or easy to speak of one’s missteps. A hallmark of dentistry is “getting it right” the first time and every time. Key to this commitment is a business model that sees 96-99% reimbursement of billed fees from dental insurance, and an EBITDA that reflects the profits they’ve earned .
What if the dentists weren’t getting paid? What if they did the work, paid the staff, paid the lab bill and did the treatment without paying themselves? How long could they hold on? More often than not this is the story we hear from dentists who start billing medical insurance. Here’s Dr. Rod Willey’s story:
- WILLEY WASN’T GETTING PAID . . .
Every weekend event, online course and extra training Dr. Rod Willey attended prepared him for being a dentist who exclusively treated sleep apnea and facial pain. When he was ready to make the final transition to a dedicated sleep practice, he brought in one of the ‘best’ trainers and consultants in the field, to his practice for a month of training, on three different occasions. Dr. Willey wanted to make certain everything was done exceptionally well by his hand and that his staff would not be left to wing it. Training was key and he paid the price for every minute of it.
Dr. Willey purchased all of the recommended equipment and followed his training in every aspect. Patients flocked for treatment and his team provided exceptional care for each one. For the first year, Dr. Willey had more denials than payments. He suffered great losses and found himself with over $300,000.00 in unpayable claims and another $60,000 to the so-called ‘expert’ trainer. This left him with two choices: Either pass the fees onto his patients, surely making them very upset, or write it off. He choose to write it off and here is what he learned:
- Don’t expect to get Medicare payments for cone beam x-rays just because an ‘expert’ tells you that you will. Ask a wet-finger dentist, not a lecturer
- If you have a medical insurance contract, know that the fine print may not allow ‘pass through billing’ which means you cannot charge for anything but the technical component of the Cone Beam CT and home sleep studies. Even though Dr. Willey had qualified doctors that he was paying for the reads of both services, his pay was reduced to only the technical component.
- Insurance companies will tell you that there is coverage for something over the phone because they are looking at the overall company policy. If they do not look specifically at the Medical Policy for that particular group, they may be giving erroneous information.
- Willey was quickly told that he cannot go by what he is told over the phone and that he should have done pre authorizations. And so he did. He would pre auth, receive approval and feel confident that he was going to get paid. But that was not the case.
- Every pre authorization comes with a disclaimer stating “not a guarantee of benefits.” What Dr. Willey learned is that when he sent the medical records and they were reviewed, the patient’s medical criteria meets medical necessity, and therefore the approval was sent. However, even at this step, if that patient’s specific group policy contained an exclusion for the treatment that was being provided, the claim would be denied. Therefore he learned to not only pre authorize, but he also learned to read the medical policy certificates.
- There are many medical insurance rules that a dental person would not be familiar with including timely filing, medical contracting requirements, medical policy certificates and documents necessary for coverage just to name a few.
- Willey learned that he can get the best in the business to train him, the best equipment and the best staffing and still not get paid!
NOW DR. WILLEY IS GETTING PAID . . .
In the dental world it is customary to hire one person to oversee dental insurance, whereas in the medical world it takes an entire team. And so Dr. Willey built a team. The team begins at the front desk where
his business staff is laser focused on sleep medicine and nothing more. His clinical team is laser focused on one thing and one thing only – sleep medicine. The back office team is laser focused on one thing and one thing only – sleep medicine. And Dr. Willey himself is laser focused on one thing and one thing only – sleep medicine. Together they have connected all the dots – both the visible and the invisible. Listed below are a few implementations that made a big difference:
- By learning how to think like a physician, Dr. Willey now connects the dots that insure reimbursement for the treatment he offers.
- Working with Medicare may seem overwhelming. However, once you master the rules, the game becomes easier and more enjoyable to play.
- He has devised specific internal protocols to follow prior to beginning treatment so proper expectations are set and he avoids potential misunderstandings with patients regarding insurance coverage.
- Willey started out using dental software and tried to adapt it for medical needs, but in order to truly submit medical claims, he found it necessary to incorporate medical software.
- He has peace of mind knowing that he submits the proper exam code based on the correct level of the exam. Medical exams are not only based on the amount of time but also the amount of pertinent documentation obtained.
- A well-trained staff is the key to consistency. On-going staff training is the key to continued growth. Collaborations with other sleep doctors is the key to profitability.
- He has created reliable, reproducible systems and lives by them.
- And finally, Dr. Willey can enjoy what he does and has confidence knowing he will be paid for it!
David Gergen CDT opened his family-owned Gergen’s Orthodontic Lab in Phoenix, AZ in 1986 and now employees over 80 people. David Gergen has been a nationally respected dental lab technician for over 25 years. He received the award for “The Finest Orthodontic Technician in the Country” given by Columbus Dental in 1986. He also received a lifetime achievement award by Dr Harold Gelb Academy as Americas greatest Orthodontic technician of all time, in 2012. He has worked for some of the pioneers in the orthodontic and sleep dentistry fields. Gergen and his father John Gergen began Gergen Orthodontic labs in 1984 and have grown it into one of the most respected labs in the country. One of his proudest achievements is receiving The National Leadership award for Arizona Small Businessman of the Year in 2004. David is the Dental Director of the American Sleep and Breathing Academy and he has also taken a spot at Tufts University teaching seminars for the Continuing-Ed program on Dental Sleep Medicine.