The Everlane of Straight Teeth: Episode 4

We are going to cover a range of topics, that converge to the introduction of an idea I have been thinking about for a while.  First, I will talk about an update on insurance reimbursement and how I think that is affecting the dental care available.  Then, I will talk about marketplace realities and orthodontic pricing.  Finally, I will discuss what we are doing at Cooper Orthodontics because of the climate created by the insurances and marketplace to make high quality orthodontic care more accessible than ever.

Update on insurance reimbursement: Even for in-network providers, the miscellaneous codes D8999 codes are not getting approved.  What does that mean?

Temporarily patients are getting the upgrades for “free” if they are already bonded.  In the future, what that will mean is that anyone using insurance and an in-network provider will not have the option for upgrades. No clear brackets, no clear trays, no custom wires, no expanders, no appliances instead of elastics for bite correction.  By choosing an in-network provider you will literally be limiting the type of tools available to be used on your case.

Why is this important?  It is increasing the divide between the levels of healthcare in America.  Here is what I mean.  Before the 50’s people paid for dental work themselves without any insurance money, in other words – Fee-For-Service.  That meant that anyone who could pay some money could get care.  Since then, insurance has been available to pay a portion of the dental fee and gained popularity.  In the 90’s there began to be different types of insurance – HMO, PPO, Medicaid & Medicare that are government programs.  It seemed that people who had not had access to care before, now could get some help.

With the advent of Miscellaneous codes becoming denied, all the insurances are becoming more and more similar.  Up until now, the PPO really had a higher level of care available and you could be reimbursed where HMO and government programs had very limited offerings from a limited number of providers.

Currently, Medicaid, Medicare & HMO plans are almost synonymous in the level of care they will reimburse for on the orthodontic front – pretty much metal braces with some elastics.  Now, PPO plans have taken a step towards being similar to HMO plans.  PPO’s used to be middle tier that provided better reimbursement than Medicaid, Medicare & HMO plans even though insurance still dictated what is reimbursed or not.  Now without upgrades being approved, only the basic level of care would be available which is much more like an HMO.

For example, those with PPO plans used to be able to get clear trays or clear braces and insurance would approve that as an up-charge of the negotiated fee.  If those are not approved for in-network providers, then the only option presented to patients with PPO insurance will be metal braces just like Medicaid, Medicare & HMO plans.

Now, the concierge services have begun to emerge as completely Fee-For-Service, very similar to the way it was before insurances were ever available for dentistry.  These doctors have most flexibility and you may pay more or if you pay in full you may be able to negotiate, but get what you and doctor decide together is best for you regardless of what an insurance company or government employee thinks may be cost effective.

Because of the way insurance is approving (or not) procedures, driving negotiated rates down for in-network providers, and making it more difficult for out-of-network providers to get reimbursement, there is a divide in the type of healthcare available to Americans that keeps getting larger and larger.  If insurance is used, the tools available are limited and quality of healthcare decreases.  Those without insurance and are poor, have very limited options to receive care.  Those that don’t use insurance but have enough money to pay for it anyway have all the options available and can receive a higher quality care.  Eventually, if this pattern continues in America, there will be those that can have good healthcare and those that cannot have the good healthcare.

The other thing that has occurred is that Orthodontic cases have not gone up significantly in price.  There is no one answer on why that is, but there are many factors that are discussed, such as:

  • Competition from corporate dental clinics and clear aligner suppliers advertising pricing
  • Marketing that makes it seem like any clear aligner from any supplier is equal in value
  • General dentists keeping orthodontic cases “in-house” instead of referring them out, but charging less than the specialist makes the comparison between the two hard for consumers
  • Better technology and better systems have allowed increased efficiency, decreased amount of time for the doctor on each case and therefore one office can see a higher number of cases in the same amount of time
  • Insurance companies “in-network” pricing
  • Cheaper supplies (yet not the same quality supply) available and used by those trying to offer the lowest price

Either way, orthodontists have traditionally used a model of “I work until the case is finished” rather than charging for the exact number of appointments or brackets or whatever.  There are definite advantages and disadvantages to this type of model, but one disadvantage is that there has traditionally been a lump sum or large down payment at the beginning. As we went over in the first episode of this series, there are so many other things that go into the price other than the appliances placed at the beginning.  The orthodontist is estimating how many appointments it will take, how much chair-time it will take, how much supplies will cost, etc.  There is a minimum amount needed to cover the cost of a case in general and we have broken that out into a 30 month payment plan and if you finish in 30 months or less – which most orthodontic cases finish in about 20-22 months – then that is all you will pay.  Only if you are in treatment longer than that will you continue to pay the monthly fee.

At Cooper Orthodontics, we have taken on quite a few transfer cases for a monthly fee and it got us thinking – How can we offer this to more people?  To do this, we are going to try a subscription-based pricing model.  The first 30 people that come in for silver, metal braces and qualify for the program will be able to get braces without a down payment.  The monthly subscription will begin and continue until the minimum amount for a case is met or until the case is done.  This means that if you are more efficient than I estimate – by not breaking brackets, having awesome oral hygiene and wearing your elastics or other appliance religiously, you could save thousands of dollars.

This is a really amazing for anyone who has been putting off getting braces because of the cost required at the beginning of treatment.  Once again, this is for silver, metal braces only.  We are keeping our traditional pricing models for the other types of treatment and more advanced cases.  Give us the code on the podcast for a special reduced monthly subscription rate.