Very Dental: Making Dental Insurance Sexy with Teresa Duncan

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[00:01:30] This is a production of the Very Dental Podcast Network. This is the Very Dental Podcast. Welcome to the Very Dental Podcast, where you'll find entertaining and relevant conversations with visionaries, clinicians, and your friends in the dental space. Now, here's your host, Dr. Alan Mead.

[00:01:58] Very Dental people, welcome to another episode of the Very Dental Podcast coming to you. I'm not going to say live. I said it yesterday. It's not live. This is recorded. Live would be like streaming and have all kinds of lights and cameras. No, it's a recording. But I'm in the same room with the person that I'm talking with, so that's kind of cool. Here today, she's been on the show a bunch of times. I don't know that we've ever done one live before. Maybe we have. No, I don't think so. Teresa Duncan, welcome to the show. Thank you so much, Alan. It's so nice to see you in person and not just in Facebook Messenger.

[00:02:27] I know. It's wild. It's wild. So, Teresa, she's been on the show over the years a bunch of times. She's known for a lot of things. Honestly, she's sort of the go-to on a lot of insurance stuff, office management. But a lot of times, it's the... I'm not going to lie to you, Teresa. It's the least sexy stuff for a dentist. If you want to get a dentist's attention, talk about, you know, the... Well, implants. Implants are big. Always implants because it's a high-dollar thing. But like when you're talking about the best way to...

[00:02:57] Maybe you might want to drop an insurance or manage something like that. That is... Dentists are like, I don't even want to talk about it. I got to tell you, I think there's two different schools. There's, of course, the school where like you... For you, it would... You were... Eyes would roll in the back of your head. I get it. But I'm getting a lot of dentists coming in. And one of the best reviews I got from my class was you turned a murderously boring topic into a fun one. And that's what I have to do because it can be. I mean, I love it, but yeah. No, I get it. That would be like me going in and hearing about OSHA and HIPAA. Like I fall asleep.

[00:03:27] I get it. The people who are presenting on OSHA and HIPAA also fall asleep because it's the worst. I will say this. I was having a conversation with someone yesterday who was sort of ranting and raving about how there's so much online CE that people have kind of forgotten how to have CE in person. Yeah. But I'm going to say this. OSHA and HIPAA and the eight hours of DEA CE that I had to take so I could renew my license. That's really good for online. Yeah.

[00:03:56] Because you know what? I can turn the lights out and close my eyes and probably pass the little quiz thing and be done with it. You know, it's like... You know what? Yeah. They could package it as ASMR or whatever that is, right? Right. Well, it's... I mean, what's funny about this stuff... Okay. A lot of the required stuff and a lot of it is team required stuff too. It's not just dentists. It's like team required stuff. It's like because it's the required stuff... Okay. This is a hot take. They put zero effort into it. They give someone a mic and they're reading the slides. I'm like, shit, I could read those slides. You could.

[00:04:26] Just give me the slides. Yeah. Make some jokes or something. Yeah. And I think that's why I still get booked places because I have to turn it into fun. And I know the pain points and all that, but compliance is not sexy. It's not fun. And part of what I talk about with insurance, a lot of it is compliance. Yeah. You got contracts and all of that. Yeah. And it is not fun for me to tell you all that you have to be compliant with things that to me don't make a lot of sense, but you have to do it. They never made a lot of sense, and that's why people have trouble with compliance because they're not intuitive.

[00:04:56] Well, let me give you an example, Alan. Let me just drop some unfortunate knowledge on people if they're not aware. Yeah. And I apologize in advance for anybody who's like, I never- He's going to drive off the road after hearing this. Yeah, like Alan never have her back on again. So we are all seeing a lot of Medicare Advantage plans coming in. Yes. This isn't big Medicare. This is Medicare through like Delta, Aetna, Humana. Yep. So what I found, I always thought if you're a Medicare Advantage provider through Delta, whatever, you, if you're participating, you do have to take fraud, waste, and abuse training.

[00:05:26] And that is direct from the carriers. That's direct from CMS Center for Medicare and Medicaid Services. As I go on, I have been told, and I ask lawyers, I ask billing lawyers this. You actually have to take fraud, waste, and abuse training if you are submitting claims on behalf of one. So even if you're out of network, everyone, this is like Ocean Hip, everyone in your office has to take it. Yeah. And for some offices, it's more advantageous to bring in somebody to teach the whole team. Like if you've got 20 people, right?

[00:05:53] And I don't do that, so I'm not trying to pimp myself. I don't want to do it. Please don't call me. Does it have to be a course directly from that company, or is it a generic thing? Here's the thing. If you participate with Delta, if you participate with Aetna, you go to the Delta site. Yeah, they have a course, but will Aetna take that? Yeah. So I think you have to go, right? So you have to go from someone who has the training and experience and can get you the forms, or you go to the big training, Center for Medicare and Medicaid Services. And I can send you the links. Yeah, yeah.

[00:06:20] We should, honestly, let's put the links in the show notes just because everyone's like, oh, God, really? It's everybody. So even my managers now, when they onboard someone, you know, like they have to look at the manual. Now they got to look at this. And am I saying they're going to come in, audit you? No. Dentistry is not high priority right now. Yeah. It could be, though. But you know who, this is interesting. CMS is not going to come after the dentist. The insurance companies administer these plans, they're the ones who are responsible for making sure their network is compliant.

[00:06:48] So if they're looking for a reason to audit you and they just throw that on there, will you be compliant? Or if they're looking for a reason to dump you from the network? I see what you're saying. Do you see what I mean? Yeah, yeah, yeah. So don't give them a reason. That's probably more, yeah. Because honestly, I think probably the auditing thing is really, my suspicion is that's pretty labor intensive on their end too. It is. They don't really want to do that stuff. But it would be, like you said, that's just a reason you could be giving them. Well, I'll give you a little secret too. It's funny with pediatrics, you know, Medicaid, there's so much fraud in Medicaid.

[00:07:18] Yeah. So I've talked to several auditor companies, and if they find an office that passes their audit routinely, they go to that office all the time because it's not hard for them. They already know. Oh my God, that's evil. So there's a pediatric practice in Colorado, and she was like, yeah, I know them. They come with donuts, and they're in and out in a day. It's amazing. If your auditor is bringing you donuts, I'm sorry, that's a red flag. I think you're doing something good, actually.

[00:07:46] They're probably doing fantastic, but they already know they don't need to audit that person. Come on. Right. Come on, but they know that, yeah, if your auditor is bringing donuts. It's so funny. That's funny. But, you know, you find out these little things like that, and to me, that's fascinating. And that's why I love finding out the behind the scenes. And I work very closely with the ADA. I'm on several committees there, nominated, not just, like, force myself on. And I work very closely with the carriers. I'm a member of National Association of Dental Plans, and I think both of them see me as Switzerland.

[00:08:15] So when I chime in on a post or something, which I actually don't on Facebook as much because it's just so, sometimes it's so vicious out there, right? Yeah. But when I bring information, it's because you guys need to know it. And then I'm on the back end telling the carriers, look at the administrative burden you're pushing on us. You're complaining about your call centers being inundated and the costs going up, but your stuff is hard to read. We can't find information. And it's just very frustrating.

[00:08:42] So they're hearing it from me, and I'm getting you guys to understand that the amount of claims that go in with bad information is awful. Yeah. Because I sit in claim reviews, too. Yeah, yeah. And what that consultant reviewers are looking at, we send in terrible claims. Mm-hmm. And documentation is something. Tell me more about that. Like, let's just say you wanted to say, okay, if you want your claims to just be better, what do we need to do to make our claims better?

[00:09:10] First off, dentists are like, I have no idea what the claims look like. I know nothing about them. So that's, I mean, that's real. But I'm sure that, like, people who deal with claims, I'm sure there's tons of things that... Give me a good radiograph. Okay. Give me a good image. Give me one. And you know what? If your assistant tells you they were hard to get an x-ray on or a hygienist, I don't care. I need an x-ray. Mm-hmm. And honestly... And it needs to be, needs to show what they need to see. Yeah. So don't cut the apex off. Don't have, you know... Exactly. And have it be current.

[00:09:37] Why, I mean, why is the last film for that endo three years ago? That doesn't make sense. I know why. Because they forgot to take it. That's why. Yeah, probably. That's why. But, and the reality is like, well, okay, here's the classic example. Every dentist knows this story. If, okay, if you're not scanning, if you're taking impressions... Yeah. And your assistant comes in and says, is this good? They already know that it's not. Right. It's not. They wouldn't... They would put it in the jar because they know that it's amazing.

[00:10:06] When they ask you, they're hoping you'll say, it's good enough. Yeah. It's fine. Whatever. You have to do it. Yeah. And like, the reality is, I don't want that ever. But, you know, human nature, man. So, let me push back a little bit because here's my thing. Because I love dentistry. I love it. I don't want you guys to ever be in front of a state board and not be able to protect yourselves. I don't want to ever see you guys go. And I've done expert witness testimony. It's awful. And the lawyers will say, we can't even defend you because your notes aren't there.

[00:10:35] So, when they're like, well, these insurance companies, F them and F this. And why do I need to do all this work for them? You know what? It's not that. If you document to the level of the state board, if you document to the level of your malpractice carrier, the insurance stuff takes care of itself. So, I'm not sitting here going, please give insurance everything they want. Yeah. I'm saying protect yourself. Sure. Because it's the crazy lady. Yeah. The same documentation or the same, you know, high-level claim is the same kind of documentation you need to let them know about. Yeah.

[00:11:05] So, you're saying excellent radiographs. Excellent. Yeah. You know, like that needs to kind of be part of the culture of the office, too. Yeah. When they realize, you know, like in the, you just said something that's a classic, the person that's really tough to take an image on. Well, then put it in the notes. Yeah. That patient was a gagger. We tried three times. Whatever. Put it in the notes. But also, the other solution is, the other solution is that you can basically have the team do it or, you know, there's always tricks.

[00:11:33] There's always, you know, typically it ends up being two assistants rather than one assistant doing this or something. You know, there's always tricks. And I think it's worth doing. And this is why the onion, this is an onion. So, to me, when a dentist has an excellent assistant that knows to document and is part of the comprehensive evaluation and is asking questions, they're worth their weight in gold. But you don't see it as often. Yeah, yeah. So, one of the questions, like, here's a quick thing. Like, when a dentist is saying, I'd like to replace number 15 and the assistant is charting it, what I want the assistant to say is, how old do you think that crown is?

[00:12:02] And have the patient answer. And then it goes in the notes. Patient stated crown is way over 20 years old. Great. Because me as the insurance coordinator, I'm going to make sure that that's somewhere in your clinical notes. My assistant, hopefully, is going to take that information and pull it to the day you do the crown that says from comprehensive exam. Patient stated it's over 20 years old. I need that. And here's another thing. The insurance companies do not want our narratives. They don't want narratives. They want screenshots of your clinical notes. Yeah. Oh, interesting.

[00:12:31] That has been really hard for dentists. Interesting. And I say this in classes, and I say in class, which one of you now is going, oh, no. Because your doctor's notes are poo-poo. Yeah. You know? There's a lot of them, yeah. Yeah. And so, honestly, they don't want your, and this is in almost all of the insurance manuals, narratives are not considered to be used for utilization review. They're not adequate because they know it's people like me, who I'm not a dentist, writing narratives. I wrote gorgeous narratives. Mm-hmm.

[00:13:01] They were accurate, but they were not clinical notes. That's very interesting. So, one of the things that I've been considering, I've talked about on the podcast, and I've been considering, I always do everything slowly, but there are now essentially AI-based notes where it sort of records the appointment. Yeah. Ambient listening. Yeah. It's ambient listening. And I got to tell you, AI can generate some crazy stuff.

[00:13:26] But the other thing is, is that AI, I feel like the most important value of AI outside of reading radiographs, which, frankly, I think at some point it becomes better than a human being because in any case. Yeah. But as far as that sort of thing, it's like, it fights the blank page. Yeah. So, it probably gives you even more than you need. Mm-hmm. But it also is like, okay, I have to read through this, make sure it's accurate, because AI can do crazy shit. Right, right.

[00:13:54] But on the other hand, like, depending on what you give it, for instance, I use an AI program for show notes. Actually, I use two. Mm-hmm. And they generate show notes that are so much better than I've ever done, even when I'm listening back through the episode and being, because it's just, that's what it's good at. But when you think about it, how can it do that so well? I've given it the transcript. I mean, like, the prompt couldn't be any better. Yeah. It's literally creating the notes off of the document, right?

[00:14:22] Oh, we should talk about that, because I use CastMagic, and they actually can create quizzes. Yeah. They can create, like, even sarcastic titles. It's wild. It is wild. Well, I use Descript right now to do the, it's really funny, I don't probably even need to use this, because there's so many programs that can generate a transcript. So, that generates a transcript. I cut and paste to go over to Google Gemini, because it's better at it, right? Yes, yes. It's wild to think that there's AIs that are maybe better at this.

[00:14:46] But AI really depends on the prompt that you give it, in a lot of cases. I mean, you can use it to answer this question that I don't know anything about. That's one thing. But this is different. I'm giving it the transcript. And in this case, like, I think the software that we talked about on the show a few weeks ago, it's called Freed AI, and it's actually meant for medical. But the reality is, he says, it does really well with dental. And he literally just has his phone in his pocket, and he's running it on the app.

[00:15:15] And then it generates a note. And, of course, he goes over the note. It's usually really close. But also, it's not the blank page. You're not trying to type out and remember what you did three appointments ago and all that crap. So, it's like, it makes a ton of sense. And so, you're saying this is great. I worry about privacy violations. Well, you have to get the patient's permission for it, obviously. But what's great is it records the patient's concerns. Yeah. And that helps tremendously in court, you guys.

[00:15:45] Like, if a patient states that they were super happy with their smile and then they sue you, it's right there. Yeah. So, there's a couple companies, because I get asked for input on companies like this all the time. They're almost there in dentistry. But I'm watching the medical side, because the medical side, yeah, there's a lot of ambient listening for clinical notes. But the legal stuff is coming, the privacy stuff. So, it's going to, whatever happens to the medical side of notes is going to affect us, obviously.

[00:16:10] But I think right now, there's nothing wrong with using something like that, as long as the patient is aware. I mean, you're still writing your notes, but I'm telling you, you guys forget stuff. I mean, I was an assistant. You guys forget stuff. Yeah, of course. So, why not use that? Details, a lot of times you're writing notes. I'm like, this isn't an important detail. And then probably, maybe don't make that judgment. Sometimes you don't really know there's a lot of details. I'm telling myself, I'm like, okay, so here's what I would do if I was using that, which is to say, this is a clue. I need to just start using it.

[00:16:40] I would vocalize things more specifically because I want it to show up in this note that I'm not going to be writing. It's going to write itself. So, in other words, you know, when the patient, you say hello to the patient and you say, so you're here for, your understanding is we're going to do a crown of 15 today. And the patient says, yes, that's covered a whole bunch. First off, you have said that's what you're doing. So, it's in there.

[00:17:06] And I mean, honestly, and you could even say, well, you know, we diagnosed this with a fracture in it and that's the reason that we're doing this. All of a sudden, I'm like, all that's in there. The diagnosis, the prognosis, all that. It would be super easy. And it's actually something the patient might well be interested to hear or remind. Maybe, maybe not. But the reality is, if it's getting in the note, that's less work you have to do. And it's super protective. So, I'll give you an example. You guys get into the pulp and it needs a root canal.

[00:17:31] So, you guys always stop, or you all always stop and you explain it, right? What if that was recorded and the patient said, okay, I guess we should do it. Let's do it. And that's recorded in the notes, too. And you may even have the audio. Because the patient's coming back and saying, I didn't know that it was going to be this much extra money. But here's a case that I was talking to one of my lawyer friends about. And it was a patient who actually had trouble reading.

[00:17:57] And he did not admit that he didn't understand what was handed to him. And they had verbal, you know, and they didn't have it in the notes. But what they had was the assistant testifying that she had heard a verbal yes. Yes. Now, if it was ambient listening, you would have that. So, I think there's a lot of room for that. And then the ambient programs now, there's one in the UK that I was looking at. And they can do it all here. But they can now generate, if you're doing medical billing, you can generate letter of medical necessity.

[00:18:24] If you're a specialist, it generates what happened. And then you just add your comments. This is an amazing reduction of clinical administrative burden. So, I'm really excited for you all. It's still a work in progress, but I can see that this is where it's going to be going. Well, and the admin side is using it. So, I have a video on my YouTube of how I used it to write an appeal for crowns. And, of course, you've got to look at it because it's going to put stuff in there. And it's got to match your clinical notes. But I don't write narratives.

[00:18:52] But when I do have to appeal something, I have to write it. And then my doctor okays it. But AI is so good at doing it. And it pulled in sources, citations. And then I could put that in there. I'm teaching a course at ADOM, the Office Managers Association, on AI for the administrative team. And I'm going to come with prompts. How to do your marketing. How to do your HR. Come up with a job description. And I know a lot of them have not dealt with it. But, man, it's coming. And we need to do it.

[00:19:20] I'm blown away by the voice AI that sounds amazing. And they're never grumpy. They answer the phone. Oh, really? You've used them. Before we go to that, I want to say one thing that's really funny. Dentists, maybe people that went to better dental schools than the University of Minnesota in the mid-90s. But the fact is we need to have a diagnosis specifically for treatments.

[00:19:45] And there's a lot of dentistry that the diagnosis, I would say, is implicit. In other words, what do you see? You see gum disease. You see caries. And you see broken teeth. That's like 95% of what we see. So we're like, of course that's what it was. The problem is it doesn't matter. And even then, you have to state that. Yes. Even though it's super fucking obvious. You've got to state it. You've got to think of the dummy and the jury. Yeah. That's what I said. And I don't want to live like that.

[00:20:14] But you kind of have to. And the reality is it's actually probably great for the patient to hear it again. Oh, yeah. Right? Oh, yeah. Like the reason we're treating this tooth is because. And the other thing is there's a difference between a cavity and tooth decay. There's a lot of stupid stuff like that. And if we just verbalize stuff in a weirdly awkward, obvious way so our AI can hear it, it's good for everyone. I think so. And I'm saying this. I'm spitballing because I'm not doing it yet. No, no.

[00:20:41] But I think to myself, I'm like, I don't like writing notes at all. No one does. No one does. And I mean, it's not very expensive. I'm like, I would pay anything to not have to do that. Oh, my God. And you know what? Here's the thing. There's one company that was showing it to me. And I said, what you need to put on here is a reminder that this needs to be done before the end of the day. Yeah. And they were like, oh, why? And I was like, oh, you guys. Yeah. This is going to stack up for weeks. No, you have to do it. And so it's going to be a learning curve for sure, as it always is.

[00:21:11] I mean, you and I, about the same age, we have seen more technology in our lifetime. Oh, yeah. You know, the younger dentists coming in are totally like, oh, this is normal. You and I have seen huge changes. So for me, I've realized the value of jumping on anything that's going to save you time. Yeah. And like the AI for images is amazing. I close so many cases with just regular black and white and gray. Yeah. If I had that. Yeah. Oh, my gosh. Yeah. Yeah. That'd be amazing. It's kind of, okay.

[00:21:37] So along those lines, I have not, phone answering AI is what you're talking about. Is that right? Yeah. Yeah. So talk to me about that. First off, that seems to me, it's like, oh, I don't know. But you're saying it's pretty good. No. It's really good. And if you train it right, they can answer insurance questions. They can answer this. And here's my son. My son is 25. You have a younger son too. My son is 25. I don't think, he said he would not have a problem talking to an AI person. Well, that's the next question.

[00:22:07] Patient acceptance on this is going to be, okay. First off, there's the thing of, can you tell it's an AI? I think I can tell when stuff is like that mostly now, but maybe it's going to get good enough that you can. I think it's going to get better. Yeah. Will, is there an ethical requirement that the AI says it's an AI? I don't know. Oh, now that's interesting. Because I feel like a person talking to an AI, not thinking that they're talking to a person, that might piss someone off, right? It might. Yeah.

[00:22:33] But you know, I think it's other industries that always prime our patients for us. Yeah. That's a good point. Look at credit card fees being accepted in so many industries and we're over here like, oh. Yeah. And then also paying money at the time of service. Like, why did we take so long to do that? Yeah. But grocery stores and Best Buy, they're like, where's the car? You know why? It's because medical doesn't even talk about money. No, they don't. They don't. Oh my gosh. That's how, well, that's what we should talk about for the rest of my life because it is literally.

[00:23:01] Listen, medical, I hate to say it, and I'm maybe five or six years away from retiring. I think we're going to be wrapped up in that whole ball of wax by the time I retire. Okay. So here's the thing. Here's the thing. Okay. I'm going to say, oh, this is great. It's perfect. My son, we had last March, we were in Indianapolis and we went to the, we went to a great museum. If you're in Indianapolis, you need to go to the Indianapolis Children's Museum. It's frigging amazing. It's like one of the best museums ever. And then we had the zoo the next day.

[00:23:30] This was a spring break thing. And this is like, great. Okay. Middle of the night, my youngest son wakes up and he would love that I'm telling this. He had, he had, he was very, he had a lot of pain in his groin. So my wife, like emergency room kind of thing. So she took him over to the hospital and they, it turns out the Indiana University is like basically in pediatric testicular torsion. They're like number two in the world. What are the odds? They did surgery on him five o'clock in the morning.

[00:24:00] She took him there at midnight. He had surgery at five o'clock in the morning. We were driving home by 10. Okay. So it was amazing. And we have insurance. I pay out the nose for my insurance. No kidding. And so I'm like, thank goodness we have insurance. You know, thank, we got a bill like, okay, that was, that was maybe early April last year. We got a bill like in December for the whole thing, $27,000, like do now. And I'm like, okay. Wow. And I'm like, Deb's like, of course I gave him the insurance stuff.

[00:24:29] I mean, the way that they seek money is send you to collections and ask questions later. And I'm just thinking to myself, the insurance had no idea. And Deb gave them the insurance information again. Oh, okay. We'll submit this. I'm like, eight months after the fact, they're asking these questions. Well, and $27,000. And of course, nothing was talked about money-wise at all. No. Not a freaking thing. And it probably went down to $10,000 after that. Who knows? Who knows, right? Yeah.

[00:24:59] But I mean, they didn't even contact the insurance company first. And it's like, why do we have insurance? It's for stuff like that, realistically. Yeah. I mean, dental insurance is a whole other animal. Well, and now medical debt, anything over $500,000 doesn't hit the credit report. So there's no impact there. So now, if you've got a patient who's a deadbeat and good at being a deadbeat, guess what? Yeah. They're ghosting on you. Yeah. We have to be very careful as business people. Oh, yeah. Totally. You cannot extend credit anymore. Yeah. Yeah. So it's- It's really funny because I've heard a lot of people talk about, no, no, no, no.

[00:25:29] This is how you really make cases work. But you're saying, and they're like, we have a very low rate of failure. I'm like, well, maybe you do, but I've had a high rate of failure. You're on that in the past. Like, that's not worked out so great for me. They might be in a great area. Yeah. You know? Probably demographically. If you're not in a great area, then yeah, you've got to watch it. Well, and the other thing is there's people who know this stuff know this stuff, right? Yeah. But what bugs me about it more than anything is that you have anything done. There's never a discussion of what stuff's going to cost.

[00:25:59] I take multiple medications for diabetes, and literally every January is like, let's roll the dice. We'll see how much. You know, I go to pick my medication up, and it's like, it's before we've paid our deductible. So it could be $25. It could be $1,000. I don't know. Not sure. Let's see. Well, you're getting insurance off the exchange too, right? Because I'm self-employed. Well, my husband and I, you know, everybody works for my company, so we have to get off the exchange, and it is like, I mean, and I know insurance. I'm like, my head is spinning trying to make sure we get a plan that covers our insurance.

[00:26:27] And then we have to say, okay, well, if my doctor, who I love, I won't switch. He's not in it. I'm like, okay, how much is this going to cost? I got to do a whole bunch of math. Like, it's not normal. Well, and the other thing is, though, is that even someone like you, and you're having a hard time with, what about someone who doesn't know anything, and they just want to go, I'm tired of this. Let's just, this costs less. Let's do that. I'm just like. Yeah, for sure. And so, you know, presenting all of this information to the patient, if we don't get it right, then we deal with a patient who's lost trust in us.

[00:26:56] But when you're out of network. Why does the medical, okay, but okay, I'm going back to the medical thing. They don't do any financial anything. Everyone always goes through with all of their treatment. How does that work? So you, oh, boy, we're getting into a big thing. I want to know. I really don't. It bugs me that this actually happens. We are seen as optional. We are seen as optional. We are seen as pain driven. You know, there's a lot of people for the two cleanings a year. Okay. So because of the hygiene shortage, you know, we talked about this in the pregame. Because of the hygiene shortage.

[00:27:24] Now I have dentists who are telling me that they are not seeing their patients twice a year because they just can't. So if they're fine, they're healthy, they're like, we'll see you in 10 months. We'll see you in a year. Okay. And that's because they just don't have the spots. Well, patients are like, but I get two free cleanings a year. So they're like trained. Again, it's other industries. The expectations that we've put forward pre-COVID. This is real, man. This is like, I'm thinking to myself, okay.

[00:27:52] The patients that have all the need stay away from you. The patients that have no need want to sit for an hour with the nice lady and have their teeth feel smooth. And they're not going to miss anything, which is, you know, mind you, I'm not, this is dentistry's problem. We have created this monster. And I think that it's not to say that hygiene isn't important, but the reality is, is that healthy people are probably going to be healthy people. And people who need it are less likely to seek it out. It's freaking crazy.

[00:28:21] And that's why in my classes, I hear a lot of people who are not pre-appointing their hygiene, which is, was a huge, it's a huge sacred cow in dentistry. It is. But they say they're putting all their healthy people every six months. So their schedule looks exactly the same, six months out. And all those people have nothing restorative. So where's the restorative coming from? You know, so, so that has changed. Now they're not pre-appointing. They're going back to sending emails and text reminders. If you want an appointment, you call. Yeah. And I don't think I have a problem with that.

[00:28:48] Now, the more I think about it because of the hygiene shortage, if we didn't have a hygiene shortage, I wouldn't, I wouldn't be saying this. But there's, okay. There's also this thing where hygiene is, hygiene is the way that, the way that it's paid for. We've always like, we've always been like, that's paid for on a healthy patient. Now, I guess that's fine. But what I'm saying is like, they pay the same in this preventative state for someone

[00:29:14] who's a hot freaking mess of all kinds of things as the person who literally, you can't do anything but polish because they're healthy. And frankly, in some practices like mine, I have quite a few healthy patients, you know? I love seeing them. Of course you do, yeah. But the reality is, it's like, the expectation of every six months came from us. Yes. You know? Like, some of them might say, hey, it'd be great if I didn't have to. But this discussion is like, it's like talking religion.

[00:29:42] You can't really, there's a lot of people, it's a hot, it's a hot button topic. There's two things that divide my audience. One is credit card fees. And the other is this, the hygiene. And, you know, I always say in my classes, let's play a game, how much are you paying your hygienist? And I really need people to understand that when you're looking at the cost of running your business, the cost of goods, which we don't talk about a lot in dentistry, labor is huge.

[00:30:06] And if you cannot pay a hygienist $100 an hour and get $70 for a profit, you just can't. But that's my thing, you know, the reimbursements have gone up so slowly or not at all. And clearly, particularly post-COVID, I mean, like, my God, it's like, it's out of, I mean, it's something, and I'm thinking to myself, the answer for the hygienist is just go out of network. So let me, and I'll just give you the other side of it. We're so worth it. Just go out of network. Oh, yeah.

[00:30:36] That's hard. It's hard to swallow. There's one of the most popular podcast episodes. I didn't expect it. I just did a solo episode of me saying, here's the truth about going out of network. And I'm not saying you should. I'm not, there's a lot of dentists who do a good job in network. And there's a lot of dentists who should never go out of network. They don't have the personality. They're not good with patients. So different strokes, different folks. But the thing is, when you go out of network, you don't know how much things are because of, you don't know if they're paying on the low fees. You don't know if they're paying on your fees.

[00:31:06] So really, it's a crap sheet. And now we're back to doing pre-treatment estimates because that's the only way. So everybody's like, we hate pre-treatment estimates. When you talk to people, admin people in out of network offices, that's their best friend because we don't know how they're paying and they can't tell us. And here's the other thing. Reimbursements don't go up. Maximums have actually gone up. We're about between $1,500 and $2,000. I know everybody's like $1,000 for 10 years. That's not true.

[00:31:31] But here's where the business knowledge side of what I see on insurance has come in handy because the reimbursement would go up. The yearly benefits would go up if the employers asked for it. And I've been told multiple times from the carriers, we would sell people a plan with all of that, but no employer will pay. And the average amount used of a plan, $350.

[00:31:57] So when you're talking, say you and I are small business owners, if the broker says to me, why are you paying for a $3,000 yearly benefit when most of your people only hit $350, why would I pay extra for that? We've got to go to the employers. And we're all raging at the machine against the carriers. And I get it. I do. I get it. But it's the employer. So what I'm teaching in my classes is when you're telling a patient and they're like, oh, my insurance won't do this. It looks like the plan your employer selected is very restrictive. I'm putting the onus back on who it is.

[00:32:26] Like I said, the carriers will sell you a great plan. So there's so many layers to it. And this is why I don't wait in on Facebook because this is a more nuanced conversation than just they suck. It's so funny. There's so much there. You can't put hygiene out there as a loss leader.

[00:32:52] I know some people do, but you can't lose money on everyone hoping that you're going to make it back. You can't do that. That's no way to live. Margins are too slim. A loss leader in dentistry doesn't make sense anymore. No, it doesn't. Honestly, I kind of see. And actually, there are practices that are set up to just do as much hygiene as humanly possible. And I always wonder, how are those practices doing now? Because the workforce is smaller and they're getting paid more. And frankly, they're mercenary. They're always looking.

[00:33:22] They're always looking. I promise you that if you put an ad out for someone, don't worry, all your employees saw it. They for sure did. For sure. And that's just real. I mean, you want to believe, oh, they all saw it. And in my world, so I'm really close with a lot of the RCM companies. There's a whole bunch of admin people, people like myself, front office people, who decided to go out and start third-party billing companies. And some of them do a great job and some of them should never do it because they're awful. They don't understand you need a secure computer and all that. It's terrible and it's such a risk.

[00:33:51] But so I have this membership I just started, Dental Revenue Network, and it's got business owners, third-party billing company owners, and then it's got a level for billers, anybody in an office, anybody who works for those companies. And the number one thing that I am seeing is the companies who have managed to stay open for a while, they understand all aspects of the revenue cycle. Now, when I was an front office person, it took me years to understand all of that. So we are so specialized now.

[00:34:20] Alan, when I started doing insurance, I was the receptionist, insurance, treatment court, everything, right? My job now, just the insurance piece is split between a poster, somebody who's just putting in payments all day long, somebody who's making sure the clinical documentation is there and sending it in. And then there's somebody on the back end who's got to collect anything that's over, you know, and then eligibility and benefits. We've split into almost four. And then if you are a company who can have a position where you're negotiating and charged

[00:34:47] with provider relations like a DSO, that's a carrier relationship there. That's different and that's a higher paying salary. Look how, look how much it's split. The administrative burden that we've seen is what kills medical. It's very expensive. So that's why honestly, I, before COVID three or four years before COVID, I was really on the fence about outsourcing revenue cycle.

[00:35:14] I don't see how you guys don't do it now because I've got, look, I was the best case closer in the office. I was the highest paid in the office other than the hygienist. Why would I be on the phone? Why wouldn't you have me in front of, you know, that I don't want to say it's menial work, but it's mind numbing work. Get somebody else to do it. The problem is, is that we haven't wrapped our heads and the DSOs have and the multi locations have.

[00:35:41] We haven't wrapped our head around the fact that the revenue cycle side of dentistry is not producing, but it's protecting revenue, but it costs money and we're not used to that. And, and I was in grad school when medicine really went to corporate. So, and I, I'm in Northern Virginia policy and policy people were our instructors. It was healthcare management. They all said, and this is a bigger conversation. I said one time, why doesn't the AMA stop this?

[00:36:11] Because compliance, CMS, all of that, it killed small medical offices. So why doesn't the AMA do anything? Why would they listen to the AMA? The AMA is dropping membership. The AMA has no power. And I feel like I'm in freaking deja vu. Guess what? ADA, no different. Exactly. No different at all. At all. You know, and I know that there's part of ADA that, that hears us loud. There's part of them that I think needs a huge wake up call, even more so than what

[00:36:36] they've got, but when dentists are dropping membership, no one else is advocating, right? The DSOs have a lobbying organization. The insurance companies have a lobbying organization. How are we going to survive? Well, if I feel like we're going the way of, of medical where hospital systems and healthcare systems are going to buy up small offices. I'm here's my, this is my canary in the coal mine. I want to hear it.

[00:37:02] When a Pacific dental or an Aspen, when one of the big boys sells or does a partnership with a hospital system, we're five years away. And that may be even faster now with how fast things are moving. I will be retired by then, but I think I'll see it. Tell me what that looks like. I want to know, I just, in your mind, what does it look like when, when, uh, one of the monsters, and actually I think it's important that you separate out a DSO.

[00:37:27] That's a branded organization like Aspen or Pacific versus the invisible DSOs that where you don't maybe even know that it's the, that it's the, that it's a DSO. I think those are the ones that, well, you know what? The, the funding cycle comes up when it comes, when they come up for new funding, I think it's going to be healthcare systems that are going to be in the mix now because they, we have their attention. Yeah. Right. Right. So look at Pacific health. Now they're Pacific dental. Now they're Pacific health. So why is that?

[00:37:54] They've already got partnerships with medical centers in their area. Right. So they, they would love to go. They even changed to, I think Epic in anticipation of the electronic and that's the electronic medical system. So they, they have anticipated this. So I'm actually thinking they're the first ones that are going to go. Okay. So what does that look like for a dental office? So what it's going to look like is you're going to have partnerships with the healthcare centers. You might even move offices into the healthcare centers.

[00:38:20] The only way that this works reimbursement wise is on an HMO model where it's in, and then value-based care is, I don't even want to think about that, but the only way it works is if you hire the dentist. Now they're hired and the packaging and the billing is done by the healthcare system. They, there's already pediatric offices, dental, medical offices that are doing fluoride and all of that. They're set up to build a dental because we don't, in hygiene deserts, that's what's happening. So it's there.

[00:38:49] What I worry about is Medicare advantage. There's a lot there. What I worry about is that Medicare and the ADA is lobbying for this, for Medicare to absorb more of dental. Okay. Listen, I, I know that there's access to care. So there's a split part of me where I'm like, yes, we need dental for everyone. And then there's the fiscal side of me. That's like, oh my gosh, don't wrap us up. Oh my God. We want to stay out of that as much as possible.

[00:39:15] Well, my concern is that the people at ADA are, that's what they want. Yeah. And I, that, that's scary. Yeah. That's scary because we are, we are independent and that's, what's great about us. You know, we can pivot if we want to. So imagine having a ton of layers that now you have to ask for your, your formulary for your, you don't even get a chance. You don't get a choice with labs and all that kind of like, it's just, it's different. Okay. And okay. The other, the other side of that, the, the, uh, employment side of that, you've got

[00:39:46] hygienists that, that, uh, right now are, are God, I mean like just the way that they're looking for work there, you know, there's a lot of competition on what they're getting paid. They're all this stuff. So that's one thing. We just talked about 120 an hour for assisted hygiene. That's insane. Yeah. And it's, I mean, and the whole sub market is like market for substitutes is freaking insane. But, but the other thing is, is dentists are going to be, um, employed by that. And you've got these dentists coming out of dental school with $500,000 worth of debt. They need to make some money and that's a place they can do it.

[00:40:15] Like there's a lot of things lining up that, that sort of point that way to me. Definitely. And, and you know, there's, I know a lot of offices are going out of network. I see it on Facebook. Um, and, and everybody's like, yeah, there's this big movement, but I got to tell you these dental schools, the kids that are coming out. Cause I, I guess lecture at two different ones, the kids that are coming out, they're all getting snapped up ideas. So as they're all participating. So as many people are leaving networks, there's still people joining. I don't know if we're up worst. I think we're still upside down.

[00:40:42] I do think the leaving, leaving networks is a, is a luxury of an older dentist. That's, that's, you know, maybe paid off their practice. And if that has, it has, it doesn't have that nut hanging over them. Uh, and that's the, I know people in my area that have left and they're all raving about how great it is, but they always. They have the same kind of look on their face as the hostage videos that like they can't, they have to say that there's a sunk cost. Like, I mean, cause of course they're going to say it's the greatest thing ever. They want everyone to do it.

[00:41:11] And that's not to say that it's not working out for people. I don't mean to make light of that, but it does. It's also like, it sucks for, I know that it's, it's hard to do. It's hard to execute. It's hard to even understand all this stuff. And I think there's people that they're glad they did it, but it's not, it's not like you turn the switch and everything's awesome. I mean, it's like, you're basically saying goodbye to a quarter or more of your practice right off the bat. And you're, you know, I mean, there's ways to get around it, but there, but everyone I've talked to said, I thought I knew what I was doing. And the, the, the heartbreaking thing is a patient that I just, I've, I've seen forever.

[00:41:41] And I thought, love me there. They were gone first thing. And I'm like, I get it. I get it. It's going to happen. I tell them on strategy calls when they ask me if they go out of network, first of all, if somebody's not a fun, friendly dentist and their staff is not fun and friendly, I'm like, you have no business going out of network. Right. But I say to them, you're going to have your heart broken. Yes. And one dentist said to me, my girls realized they had to be sweet again. And when you're getting fed patients, sometimes you forget the little touch, you know, but and I'm thinking, wow, they weren't sweet before.

[00:42:10] He's like, no, that's not what I'm saying, but man, they got to step it up. Yeah. So yeah, that's a, it's a lot. There's a lot. There's a lot. I know. I understand why you have an unlimited amount of things to podcast about and speak about. So before we finish, I want you, let's dump all the links. I'm going to make sure they're in the show notes. Okay. So you speak at a lot of meetings, but you also have a lot of online content that people can learn from as well. Sure. I have an online insurance class they can take. I'm going to start doing some Friday sessions from home.

[00:42:39] So, you know, I'm, I'm at a stage in my life now where I, I love being on the road, but both my parents live with us and I want to enjoy every moment. I know. Right. It's like a blessing and a curse, but I want to enjoy it. I haven't flown for more than two years. I, so I choose this meeting cause I can drive here. I, I, I, it's terrible, but I'm like, I don't. Air travel is not what it used to be. But also I've got, my son is very busy with music stuff and I, and I just, I'm sort of living his life for him in some level cause he doesn't drive and all this.

[00:43:09] So the reality is, is like, I get that. Yeah. And I'm not to say that all CE online is bad. I think in person is important, but there's a lot of things that you can benefit from that way. So yes. No. And I still make it fun. Like I, honestly, I love giving webinars and my, my husband's always like. So that's actually live. That's not, that's not recorded. I have the online course that is, you know, at your own pace, but I am going to do some Friday sessions of my, of my classes. Cause I, you know, I can't talk to everybody. And I do have that, that membership.

[00:43:36] It's called dental revenue network, but the podcast, nobody told me that, you know, that's available for you. And that's your, that's the, that's the starter dose. That's, that's the one where you give them the first one free. Yeah. That's, that's how you do it. You hook them that way. It's a very good podcast. You have tons of great guests, but you also, you also like me have realized that it's okay to go alone cause you can dump your thoughts out onto the, and I think that that's, you've got lots to talk about there. So there's, I'll make sure all those links are there. Well, and you know, I'm not, I'm not consulting anymore. I don't want long-term clients.

[00:44:05] So, but if they want a strategy session, they can book one on my website, you know, and it's $2.99 an hour. I've got dentists that are just like, am I going crazy? Yeah. I'll tell you. I'll tell you. Answer. Yes. Short answer. Yes. But yeah, but drop a little about the ADOM too. Cause I, I. Oh yeah. American association of dental office management. Um, it's just association for managers, administrative people. They have a big conference once a year. There's an insurance conference coming up in May. I don't know the exact dates.

[00:44:33] Um, but it's got a ton of online learning, not just from me. And if you've got a new person at the front, you know, what I tell doctors is I know in this environment, it's tough because you don't know how long you're going to keep them. Yeah. Buy it in your name. Yeah. Set up a password for them. There you go. And then, and then let them log in and learn because there's tons of webinars. There's a lot of stuff. There's a lot of stuff. If you are a member, you've got access to a lot of stuff. That's fantastic. Yeah. So I would do that, you know, if I, if I had a new person and then, you know, if you,

[00:45:01] if I'm coming to your area, I'm at Hinman and, um, a couple other places this year, um, ADOM and, and all of that. So if I'm in your area, come and take an insurance class. I will not, it will be fun. I do promise you. It is. And that's, it's one of those we were talking about there. Those are tough ones, but yeah, I believe it. You've been doing this long enough and you know what to, what to cover. Thank you a ton for being on Teresa. This is great. And we'll, we'll do it again soon. I feel like we could probably take a lot of these topics in small bites and go in deeper, which is.

[00:45:30] I'd love to look at how I talked about it. We talked about a lot of stuff. Like I'm, my brain kind of hurts a little bit, so there's a lot there. Maybe we need to go in a little deeper dive on some of these things, but this was great. I would love it. I would love it. Thank you very much.