INSIGHT ON: Healthcare – Going Independent

Posted on Jul 1, 2015 :: Health Care , Insight On
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Posted by , Insight on Business Staff Writer
Dr. Richard Kling says the organization's CarePlus insurance plan allows him to provide better patient care and encourages patients to seek care even when their own insurance plans don't offer adequate dental coverage. Courtesy: Dental Associates

Dr. Richard Kling says the organization’s CarePlus insurance plan allows him to provide better patient care and encourages patients to seek care even when their own insurance plans don’t offer adequate dental coverage. Courtesy: Dental Associates

When Dental Associates founder Dr. John Gonis tried to improve access to dental care for patients on the south side of Milwaukee, his first attempt wasn’t a hit with the state insurance commissioner’s office.

“He had the idea of forgiving copays as a way to eliminate an obstacle or barrier to patients receiving care,” says Katherine Grueneberg, chief administrative officer for Dental Associates. Unfortunately, providers are not allowed to forgive copays.

Instead, Gonis developed the CarePlus Dental plan in 1983 as a way to make care more affordable — and therefore more accessible — for his patients, Grueneberg says.

“People aren’t as hesitant to move forward with the services that they need,” she says. “And we can also offer higher-than-average benefits because of those administrative efficiencies of being both the provider and the care organization.”

Larger providers also have developed their own health insurance organizations such as Affinity Health System’s Network Health. But some specialists also have ventured into starting their own plans, such as Menasha-based RLJ Dental — along with partners Fox Valley Orthodontics and Oral Surgery Associates of Wisconsin — which offers Wisco Dental insurance plans.

But providers don’t just decide one day to start their own health plan, then have it up and running the next week.

“It’s not for the faint of heart,” Grueneberg says. “It’s a pretty detailed, complex process. You have to know and follow insurance regulations.”

Launching an independent health plan requires licensing the insurance company and individuals to be able to sell the insurance, Grueneberg says. Providers also must hire the appropriate team to administer the insurance. Forms, contracts and certificates must be filed with the Wisconsin commissioner of insurance. “Even when it comes to marketing, we need to follow the insurance commissioner’s guidelines,” Grueneberg says. “So it’s not something that is easy to do.”

Dental Associates, which is headquartered in Wauwautosa and has offices in Green Bay, Appleton, Fond du Lac and Greenville, employs a CarePlus member services team of about 20 people. CarePlus operates as a nonprofit, allowing the savings to be passed on to patients, Grueneberg says. The team works with employer groups and individuals to answer questions, handle billing, file claims and the like. The organization also has a CarePlus review doctor to look over requests for major dental work.

But the effort is worth it because it’s helping put patients in the chairs, whether they have their own dental coverage, they need supplemental coverage or they don’t have any coverage at all.

“It brings in more volume for us, and it also helps the provider because it does eliminate some obstacles for patients moving forward with treatment,” Grueneberg says. “It’s going to help us provide the highest level of care versus a traditional insurance policy, which is a little more focused on cost.”

Dr. Richard Kling, an Appleton-based Dental Associates provider, says having CarePlus has made it easier for patients to say “yes” to their treatment plans. “It makes it somewhat more affordable for them, even if they have their own insurance,” Kling says. “So patients on the whole are much more agreeable to having the appropriate type of work that they really need done.”

Offering the insurance product has become more important as people sacrifice their dental benefits to keep health care costs down. “We deal with dental plans going back 20 years, where they might’ve had a $1,000 benefit available, and many of those folks 20 years later still have a $1,000 or $1,500 benefit,” Kling says. “There’s no way that it’s kept up with inflation.”

Bring in the whole family for treatment, and that gets expensive. “It’s a fabulous thing for us as care providers because it encourages more people to come in and receive care, and potentially get the type of care that they need, instead of just doing a big filling that’s maybe not the best for them,” Kling says.

“It helps bring patients in for us, and certainly keeps us busy in that regard,” he says. “We don’t have to worry about the fact that we can’t keep our practice busy, because it’s such a popular product with the patients.”

CarePlus continues to evolve and remodel its offerings depending on how private insurance changes, Kling says. “I know the folks down at headquarters work really hard at trying to create a nice puzzle fit between people’s own insurances and CarePlus.”

The implementation of the Affordable Care Act hasn’t impacted CarePlus quite yet.

“We sure have talked about it a lot, and we’ve researched it a lot,” Grueneberg says. “But at this point it hasn’t changed anything with CarePlus. However, we’re constantly monitoring that because the ACA is evolving as time goes on.”

The ACA requires employers to offer essential health benefits, which includes pediatric dental. But they can do that through either a medical or dental plan.

CarePlus has products for employer groups and individuals, Grueneberg says. A third-party study found that employers that offered CarePlus typically saved between 15 and 25 percent on health care costs.

Any provider that is considering whether to develop its own insurance plan would be wise to consult with the State Office of the Commissioner of Insurance.

“It is really important that providers understand that whenever they take on risk, they are conducting the business of insurance and subject to OCI’s regulatory authority,” says J.P. Wieske, legislative liaison and public information officer for the OCI. “While we can’t and don’t provide legal advice, our financial bureau often assists those who are interested in becoming a licensed insurer in Wisconsin.”