Insurance verification is a critical process for dental clinics. It helps them determine a patient’s eligibility to have the costs for an impending dental service covered. If you don’t have this information before the treatment, the patient may have to cover the service’s cost in full which may lead to souring of relationships. Yet another reason to carry this out is to remove all assumptions before the treatment. It’s always possible to mistake your patient’s insurance for a different insurance provider who you know covers the procedure. This may happen because of some confusion or over confidence or because of workload rush. No matter how well you do it the possibility of things falling through a crack is always high.
| Did You Know Dental insurance provides approximately 170 million Americans with coverage for routine diagnostic, preventive, restorative, and many other dental services. |
The fact of the matter is that all dental plans are not created equal. Therefore, when checking dental benefits for patients, especially if it is a last-minute verification, there are many things that can go past your lens undetected. Sometimes, small oversights can cost you big, triggering even bigger implications. In this blog we talk about all that you cannot afford to miss out while carrying out a dental insurance verification.
| Largest Dental Insurance Providers in US -CVS Health Corporation Market Share -MetLife Inc. Market Share -Delta Dental Insurance Co. -United Concordia Companies, Inc. |
Check List for Dental Insurance Verification with Carriers
Enquire About Waiting Periods
The fact of the matter is most dental insurance verification companies have a waiting period for some particular treatments. For instance, most dental insurers have a six-month waiting period on a full mouth series of x-rays. This may or may not find a mention in the policy wordings. Irrespective of whether you discover it on the document or not you need to get it verified from the insurance company. Again, if you forget to enquire an insurance company is not bound to divulge it to you. Therefore, as a practice, your verification process about a dental procedure must always include a query about the waiting period.
| Concepts you Need to Explain to Patients: -Deductible -Co-pay -Co-insurance -Out-of-pocket maximum |
Downgrades on Fillings
As a matter of fact, most of the times insurance companies keep downgrading procedures. This happens mostly in case of restorative procedures. One good example is white resin filling. The insurer will always downgrade this to silver amalgam filling, which costs them less, and then goes on to pay 20% of the lesser cost. The patient has to bear the expenses of both the co-pay and the difference amount. This can be a substantial amount. Likewise, porcelain crowns are downgraded by most insurers. There have been cases where implants have been downgraded to partial denture. This makes prior authorization on fillings and implants important.
| Common Denial of Payments from Insurance Providers -Payments for root planting and scaling -Payment for emergency appointment and limited exam for existing patients -Reduced payment for cleaning and examination visit -Payments for preventive visit |
Understand the Missing Tooth Clause
A missing tooth clause is a common reason to decline a dental claim. It is a clause inserted unmistakably in policy wordings to protect the insurance company from paying for the replacement of a tooth that was missing before the policy came into effect. More than 90 percent of insurers include the “missing tooth clause” or a “replacement clause.” A few include both. Sometimes patients purchase a dental insurance just because they had an extraction and therefore require an implant. As they do not understand this clause, they may end up buying the insurance only to discover at a later stage that they have to bear the expenses. Therefore, it falls upon you to make this clear to the patient after enquiring with the carrier.
| Things to Keep handy -Name of patient -Date of appointment -Contact info of insurance company -Social security number etc. -Payor ID -Claim mailing address -Office Tax ID |
Non-Dup or Non-Dual
If a patient has both primary and secondary insurance, then it may lead to some confusion about payments and create bitterness of sorts. Therefore, it once again falls upon the dental practice to make things clear upfront to the patient. Enquire with both the insurance providers to find out what percentage of the treatment they cover. If it’s the same, then you need to inform the patient that it would not lessen their out-of-pocket costs. Many patients may come to you with the wrong information. Therefore, dial up both the primary and secondary insurer to know the real picture.
| Most Important Queries to be Made -Cleanings, crowns, and build-up coverage -Tooth implant coverage -Frequencies for x-rays and panoramic -Plan benefits such as policy duration, deduction amount, annual maximum, fee schedule waiting periods etc. |
Frequencies of Treatment
Most dental insurance companies have fixed the number of visits a patient is permitted to make for a claim in a stipulated time. The limitations may be related either frequency or times. For example, one cleaning every six months or not more than two cleanings in a calendar year. Likewise, an insurer may have stipulations of what procedures can be done at the same time in a single visit. For instance, if a person needs root planning and scaling in one visit, most insurances will not permit more than 2 quadrants in a single visit. This is confusion can be sorted out by talking to the insurance company. In case you don’t, you run the risk of the claim being denied and the patient refusing to pay.
Conclusion
Like any other medical insurance, it always pays to check benefits for dental patients. Have a checklist of all the right questions ready for your carrier and if you aren’t confident its always safe to seek a pre-authorization. Right insurance verification is not just about getting claims paid, but also about winning over patients. Patients don’t expect any surprises and it’s only with proper insurance verification that you can give them an actual estimate.
Who We Are and What Makes Us an Expert?
This article is brough to you by MedBilling Experts a BPO service providers for healthcare services. We have wide experience in providing a range of specialized healthcare services to hospitals and clinics based in the US. These include dental clinics. One of the services we specialize in is dental insurance verification. We have a well-defined check list-based process to assist dental clinics round off their services n an error free manner. Get in touch with us now to know more about our services.
