D. Gregory LoPour, D.D.S., Smile By Design, P.A.

COMPLAINT:
I visited D
LoPour to solve a dental problemI was examines, x-rayed and my problems diagnosedI was then taken to a "closing room" much like you might find in a high pressure car dealerMy issues were explained to me and my insurance coverage was examinedIt was determined by the "closer" that all my issues could be resolved for my insurance coverage plus approx$I agreed to the $share for myself and made an appointment to return for the workThe work was done and I was once again assured that my part of the bill would be $1,Imagine my surprise when the bill was sent to me saying I owed over $2,after my insuranceI called the office on Septo express my concern and to make my $per month payment as agreed originallyI was told by the operator that someone would call me to see what could be done because they always want a satisfied customerI have not heard a word from the office until yesterday when I received a statement for the remaining $and a threat to send my account to a collection agency.
RESPONSE
Part 1: The Dentist, The Patient, The Consult Room, The Financial Agreement and The Dental Insurance Company
I would like to apologize first on our behalf for any uncomfortable feeling or for the appearance of "closing room" as was mentioned by the complaint In fact, when we designed our dental office we took great care to build what we refer to as our "Patient Consult Room." The PATIENT CONSULT ROOM was created as an enclosed personal space which would offer our patients the privacy they need and deserve to feel at ease talking about treatment options, dental insurance plan coverage and the financial aspects of paying for the treatment should they choose to move ahead with any of the treatment options offered So many times in our past years in the dental field, we have watched patients be told time and time again, "oh your insurance will cover that..." only to be completely blind-sided when indeed their insurance plan did NOT cover all or part of the treatment We felt the obligation to give our patients all the information that we have accessible to us in order to help our patients make informed decisions about their treatment plansIncluded in this process was the providing of a patient FINANCIAL AGREEMENT which would list in detail the treatment the patient and the dentist mutually agreed upon as well as our total cost for the treatment Also included in the FINANCIAL AGREEMENT is our best "guesstimate" of what the insurance might pay toward each of the treatment procedures that will be performedWe call this a "guesstimate" based on the limited information dental insurance companies give to us regarding what they may or may not pay for on behalf of their client who is now in our care as a dental patient We decided that giving our patients a "general idea" of what insurance may and may not cover was far better than nothing at all We hoped this would allow our patients to budget for any added expenseAdditionally, we are not a bank but we feel strongly about helping our patients receive the dental treatment they need and deserve so we decided to offer to all of our patients the option for them to pay for their financial responsibility for serves rendered over a period of time (usually two, three for four months) without interest fees Simply put, the "guesstimated" portion for which we have guessed our patients might owe if their insurance company pays accordingly, can be broken into equal payments and paid out over several monthsThis would allow the patient to receive the dental treatment needed without having to suffer needless months in order to acquire the monetary funds available to pay the "patient portion" on the date of treatmentWe have taken careful steps to explain in paragraph format on the Financial Agreement itself, the fact that the portion we "think" the dental insurance will pay is only an estimate, not a guarantee, and that the patient is ultimately responsible for any fees that the insurance company does not payThe Financial Agreement is signed by both the patient and the patient liaison employed at our dental office which reviewed the treatment, scheduled the treatment and explained the insurance benefits based on the information provided to us at that time by the patient and their insurance planAfter signed copy is then given to the patient as well as placed in the patient's digital and physical medical chartMany times, we wait months for insurance plans to pay which leads to lengthy waiting on both our part as well as that of our patients The dental treatment however, has been rendered and completed.
Sadly, both the dentist and the patient are at the "mercy" of the insurance plans willingness to disclose or not to disclose information As dentists, we have absolutely no control over or association with dental insurance coverage as the dental insurance coverage is a separate third party organization As dentists, we simply want to treat our patients with the highest level of care that they deserve, yet all too often patients become agitated with the dental insurance's lack of payment and many times see the dentist as the "bad guy" when in fact, the insurance company is the reason for the denial of paymentsSo many times, dentists are left with the remaining portion for which the insurance was assumed to cover but did not Each month we "write-off" an enormous amount of money that the insurance company and the patient both refuse to payIt is a vicious cycle that unfortunately will continue to lead to higher and higher dental costs and leads to dentists being forced into providing mediocre care to their patients because the insurance companies will not step up and pay what they should pay on behalf of their clients who are our patients.
Having dental insurance or a dental benefit plan can make it easier to get the dental care you needBut MOST DENTAL PLANS DO NOT COVER ALL DENTAL PROCEDURES YOUR DENTAL COVERAGE IS NOT BASED ON WHAT YOU NEED OR WHAT YOUR DENTIST RECOMMENDS (SADLY)...IT IS BASED ON HOW MUCH YOUR EMPLOYER PAYS INTO THE PLANWhen deciding on treatment, dental benefits should not be the only thing you consider Your treatment should be determined by you and your dentist Since almost all dental plans area contract between your employer and an insurance company, your employer and the insurer agree on the amount your plan pays and what procedures are covered Often, YOU MAY HAVE A DENTAL CARE NEED THAT IS NOT COVERED BY YOUR PLANEMPLOYERS GENERALLY CHOOSE TO COMVER SOME, BUT NO ALL, OF EMPLOYEES' DENTAL COSTSIf you are not satisfied with the coverage provided by your insurance, let your employer know(American Dental Association)
As dentist's our main goal is to help our patients take good care of their teeth Many dental offices will file claims with their patient's dental plan as a complimentary service to their patients And all too often the information the dental insurance companies share with us or with the patient is NOT COMPLETE INFORMATION which makes it a "guessing game" for so many dentists We have tried to learn to "guesstimate" as best as we can so that we can inform the patient to the best of our ability what their individual insurance plane may or may not cover Dental insurance companies DO NOT CARE IF OUR PATIENTS KEEP THEIR TEETH BUT WE DOWe spend an enormous amount of man power filing insurance claims on our patient's behalf and refiling and working as advocates for our patients to help fight the insurance companies to pay what they should on behalf of their clientsWe spend as much time filing insurance paperwork as we do performing the very thing we went to school for...dentistry.
Because insurance companies do not provide our patients nor us with the actual amount they will cover for each procedure in which we have determined is needed by our patients and for which our patients have accepted to pursue, the only way to know EXACTLY the amount the insurance will pay is to actually perform the procedure and file to the insurance company Even what we refer to as a "pre-authorized" estimate is sent back to us with HIGHLIGHTED WORDS FROM THE INSURANCE COMPANY THEMSELVES WHICH READS: THIS IS AN ESTIMATE ONLY, NOT A GUARANTEE THIS WILL BE PAID ON YOUR (i.ethe patient) BEHALF BY THE INSURANCE.
Many times, insurance will pay only a portion or nothing at all and the patient is left with the bill of the treatmentUnderstandably, they are upset and look to the dentist to make things right As dentists we receive many angered patients responses regarding the balance that insurance did not cover We are also ourselves at a disadvantage having already rendered services in which we are still waiting to be paid
Part 2: Cost-Controll Measures Used by Dental Benefit Plans
Insurance companies use UCR (Usual, Customary and Reasonable) as their maximum allowable amounts that will be covered by the planHowever, while UCR makes it sound as if this is the standard rate for dental care, it is notIt is misleading to the patients for several reasons:
>Insurance companies can set whatever amount they want for UCR chargesThey may not match current actual fees charged by dentists in a given area
>A dental company's UCR amounts may stay the same for years and yearsThey are not required and do not have to keep up with inflation or the costs of dental care
>Insurance companies are not required to say how they set their UCR ratesEach company has its own formula and the formula is meant to make a profit, not to value keeping peoples' mouths healthy
Note: If your dental bill is higher than the UCR, it does not mean your dentist has charged too much It could mean your insurance company has not updated its UCR chargesIt could also mean that the data used to set the UCR is taken from areas of your state that are different from yours.
In many ways, the dental field should be able to exist like any other "fee for service" establishment such as a restaurant or hair salon You walk in, order what you would like after hearing the recommendations and then you pay for the services rendered We believe that if this were the case, not only would our patients receive the care they really need and deserve, but the total cost of dental care itself would be greatly diminished because no extra costs would be involved with the corporate world of dental insurance companies We care if our patients keep their teeth and the dental insurance companies do notThe surest statement is this: If individuals practice their regular dental care according to what their insurance plan does and does not cover, they will loose their teeth
Although individuals may be tempted to make decisions about their dental care based on what insurance will pay, remember that YOUR HEALTH IS THE MOST IMPORTANT THINGWe want to work with our patients to give them the best possible care so they will have a healthy mouth that lasts a lifetime.
Part 3: Resolution
We pride ourselves in our customer service and if we indeed failed in this situation, we hubby apologize and will do all that is necessary to make things good and right We are not the corporate dental insurance world, but a locally owned dental office small business that practices dentistry because we are passionate about contributing to the oral and overall health of our patients We seek life time relationships with our patients and simply want to provide a high level of dentistry in both skill and education so that our patients are able to achieve a high level or oral health and then easily and with low cost, maintain this level of oral health and keep their smiles the rest of their lifeWe regret that we failed to offer the level of customer service we strive for every day and for which our patients have become accustomed to receiving from us and from our staff on a regular basisOn behalf of myself, DrLoPour and our entire staff, we apologize for the breakdown of communication on our part which in turn caused a "nonresponse" by not calling you back Somehow, that message that you called with insurance questions did not receive a returned phone call in an acceptable amount of time
Sincerely,
** *** ***
Vice President, Director of Marketing
LoPour & Associates DDS Smiles By Design
Family & Cosmetic Dentistry
Jefferson StSuite
Albuquerque, NM
w
* ***
***
www.smilesbydesign.biz

To whom it may concerm
Dr LoPour's office contacted me immediately upon their receipt of my complaint and offered to remove the excess charges from my account
I am fully satisfied by their response and as far as I am concerned the mater is closed
*** ***