Marc Ackerman

Ben Burris

One of us went to an emergency meeting of the Massachusetts Association of Orthodontists last week. It was held at a small hotel in a nondescript meeting room with about 20 orthodontists in attendance – a far cry from the pomp and circumstance of the American Association of Orthodontists’ annual session.  This meeting was way different. Massachusetts Medicaid had just significantly changed their orthodontic billing policy, put it into effect (July 1, 2017), and nobody had bothered to consult with the Massachusetts orthodontists along the way.

What is the crux of the issue? Billing for adjustments for MassHealth is no longer to be quarterly but must be done on a monthly basis (30 calendar days apart). If you want to be paid the entire case fee, you have to see the patient every month.  So, if you normally have 6, 8 or 10-week adjustment intervals, you will receive $1000-$1500 less per case. To be clear, Medicaid is not saying that you need to see your patients monthly, just that you must see them monthly to get paid the full amount.

While word of this Medicaid setback was quickly reaching orthodontists statewide, a simultaneous “blow to the wallet” of Massachusetts dentists occurred. Delta Dental of Massachusetts (2.2 million members) was allowed by the State to offer a low-cost Total Choice PPO plan to Massachusetts businesses. It was reported in the Boston Globe:

“Delta said the new plan is necessary to attract new budget-conscious businesses and to account for rising dental costs that can lead to increased premiums or reduced access to care. Employer groups, including the Associated Industries of Massachusetts, endorsed Delta’s new plan.”

Dentists receive higher reimbursements under Delta’s traditional Premier network, which is still being offered along with the PPO. It is clear however, that the low-cost plan will ultimately phase out the Premier plan.

What does this mean? The insurance gravy train is reaching the end of the line (but not just in Massachusetts) and Orthodontists can no longer count on public or private benefit programs to offset our high fees that we are advised by consultants to raise annually.

Additionally, we’ve been hearing from orthodontists across the country that private insurance companies are requiring orthodontists to fill out forms assessing the “medical necessity” of the orthodontics they want to render on an insured party. We have received these requests for proof of medical necessity from insurance companies also and believe that insurance companies will embrace this as the norm in the near future. Expect that soon you won’t get verification of benefits until AFTER you show that the insured party meets the insurance company’s definition of medically necessary orthodontics. All other cases will be denied any orthodontic benefit.

Finally, we aren’t sure how much news you’ve watched of late but it is a safe bet that Medicaid funding will be cut at least to some degree. When this happens, it makes sense that the least invasive, elective dental work (orthodontics) will be the first dental benefit to see the axe.

“What do I care? I don’t accept Medicaid,” you might say since the majority of orthodontists don’t.

But we believe you’re overlooking one important factor in doing so. When the Texas Medicaid system crashed a few years back, it was not only those who accepted Medicaid that were impacted, it was also the private practices in Texas and surrounding states that felt the influx of hundreds of orthodontists who used to work for Medicaid providers hitting the job market and opening practices. What if this happened on a national scale? Is your practice in positon to weather that storm? ***

So what is an orthodontist to do when the things we hold dear – medical necessity, insurance benefits and Medicaid paying for orthodontic treatment – are all fading to mist? Should we hold a vigil for the deaths of these beloved financial conduits and bemoan the fact that those patients can no longer visit us for treatment? Absolutely not! You could view these changes in a negative light but we believe that these three factors are more of a hindrance than a help when it comes to overall access to orthodontic care. We also believe that if orthodontists lower our fees to an affordable level and modulate service to fit price we will more than make up for the “lost profit” on any individual case with a much more sustainable, higher volume, model. This sounds darn good to us – profitability, sustainability, increased access to care for Americans – and we cannot understand why our peers don’t see it as such.

Most industries that are being disrupted in the way orthodontics is cease to exist in their traditional form but we don’t see that happening to orthodontics any time soon. Our professional and financial future are very bright if we can only modify what we do to fit the new reality.

The world is changing whether we orthodontists like it or not and it is reminiscent of change in other industries. We do not have to imagine how this will play out. In the book The Inevitable, Kevin Kelly discusses the rise of Napster and other file sharing software and the music industry’s reaction to The Inevitable:

“The music industry did everything in their power to stop copying. To no avail. They succeeded only in making enemies of their customers. Banning the inevitable usually backfires.”

Sound familiar? It does to us. Everyone said, “You can’t make money selling individual songs for 99 cents” instead of forcing the consumer to buy an entire album like they should. But a few brave souls gave consumers what they wanted at the price they could afford on the terms they demanded and it seems to have worked out reasonably well.

Your everlasting summer
You can see it fading fast
So you grab a piece of something
That you think is gonna last
But you wouldn’t even know a diamond
If you held one in your hands
The things you think are precious
I can’t understand

Steely Dan

*** The implications of this scenario are beyond the scope of this piece but interesting to consider none the less.

6 thoughts on “They Can’t Get Away with That!

  1. I’m certain of one thing outside of death and taxes; Change is inevitable; Business need to adapt to changes or die. I would love to discuss this with you and others in a virtual mastermind group. E mail me.

    Ps I’m working on my Ortho story about struggling and fear. Should be done in a month(my own deadline)
    You can call me on my cell or Text me at 614 506 5774

  2. Ben,
    I do agree that prices must come down and we need to operate with high efficiency and higher volume. This, however, implies that all orthodontists, must be excellent clinicians and must be hard working enough to get something done and not just “social six”. If we are talking about “social six”, the price for that “service” should be substantially lower. A few years back, one of the states, I cant name it, closed medicaid ortho program based on the fact that ortho had 70% failure rate, meaning that 70% of cases were not finished to some acceptable degrees or appliances were removed prematurely based on poor compliance. Imaging that in medicine. If a tx modality had 70% failure rate, would it be acceptable to use it? Unfortunately, too many orthos, view medicaid as a cash cow, paying zero attention to quality. For those cases, “social six” ones, the price should be only a small fraction of what an ortho case costs now.

  3. I do the best work I can every day for every patient. I can only assume other orthodontists do the same. Not every case works out and I’m very slow to point fingers as it’s tough to know what causes a negative result. Obviously if there are people who don’t care about the result that’s bad but that’s ok us as a profession as well. If there are such people (and I’m sure there are as orthodontists are humans and none of us are perfect) then I’m going to consider them outliers and do what I always do – plan for what happens most of the time and ignore the outliers. What else can we do? Also, what Marc and I are trying to do here is give insight into what we see coming – you and all the other doctors out there will have to decide how best to use this information in your pracrice. Thanks so much for the insight.

  4. Thoughts—the title of this post is incorrect—yes they CAN and WILL get away with this.
    Our response will probably be a customer service model based on airlines ,trains and British Health service:2 or 3 levels of care — eg.,as in the NHS—private or first class care–low volume high service and outcome level. OR level 2{NHS} and maybe 3 -lower level of outcome and service and higher volume. We dont all fly business class all the time {at least I dont !}.The consumer gets to choose and we get to adapt to the inevitable and not try to behave like King Canute !!

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