If you sometimes find it difficult to interpret those confusing explanations of benefits received from dental insurance carriers, you are not alone! Don’t beat yourself up over it! Just know that it will get easier, as you become more familiar with insurance carrier terminology. After 39 years in the business, I still find it challenging, and even more importantly, fun!
Yes, you heard me correctly! I did say fun! I enjoy the game of it all. And it really is a game, no matter what anyone says. The rules of the game are established by the carriers, and they are ever changing! The object is to keep those dollars in the carrier bank accounts! They realize that often time’s providers and patients will accept the original benefit determination as final, and that means they won’t have to pay the claim. Take this scenario, and multiply it by thousands, and you begin to get the picture.
So, what we have to do as dental business professionals is stay on top our game! And this process begins long before we have an insurance explanation of benefits in our possession. Bottom line: if we choose to accept assignment of benefits on dental insurance as a form of payment for services rendered, we have a responsibility to do certain things:
From the initial phone call, cultivate the proper patient attitude towards their dental insurance. Let the patient know your practice accepts assignment of benefits from their insurance as a courtesy to them, but they are responsible for payment for services provided, not their insurance company.
Gather the information necessary to accurately estimate benefits. That is, confirm every patient’s benefits, and learn the key questions to ask to enable you to become familiar with their policy; what it covers, and more importantly, what it does not.
Submit complete and accurate documentation with every claim, so there is no question about liability having been incurred. This will help minimize delays in payment of the claim, and help insure healthy cash flow/accounts receivable.
Have a follow up system to track unpaid claims. I recommend 30-45 days, depending on the type of claim. (If the claim requires consultant review, often following up in 30 days is too soon).
Have a conversation with each patient before treatment has begun to acquaint them with estimated benefits from their insurance plan, as well as their estimated out of pocket expense. Use these words, “based on the information we have received from your insurance carrier, we estimate your out of pocket will be….”
Close every conversation with these words “We can in no way guarantee your insurance will pay exactly as estimated, but we will let you know if there is any difference after your claim has been processed by your insurance carrier.”
Then, print out the treatment plan, and include the message “Insurance is an estimate, not a guarantee of payment. Actual benefits will be determined by your insurance carrier at the time your claim is processed by them.”
Ask the patient, “What questions can I answer for you?”
If the patient says they have no questions, then have them sign the treatment plan, to indicate that you have reviewed the estimate with them. This may come in handy later, in the unfortunate event their insurance doesn’t pay as estimated.
Remember this: We hold the power to set ourselves up to succeed or fail, when it comes to dealing with dental insurance carriers and patients. “Knowledge is power”! And right up there with knowledge is communication. These two things determine the result. If we become more knowledgeable about dental insurance, and better at communicating with our patients, not only will our collections and case acceptance improve, but we will build long term relationships with quality patients, who will refer other patients. So, let’s keep our perspective, and realize, we can and we will overcome this challenge!
As far as the confusing, often misleading way some insurance carriers present information on their explanation of benefits, just take a deep breath, take your time, and read through it carefully. Most of the time, the answer is there, in front of you. If however, you find that after complete review you still don’t understand something, do not hesitate to pick up the phone, and have a carrier representative give you further explanation. And whatever you do, always question anything you don’t understand. Many times you will find that they made a mistake, and there are additional benefits to be paid. In spite of all their tactics to confuse and keep dollars, they will pay the claim once they are certain their liability has been proven.
Some items to look for on insurance EOB’s are:
“Charged or Billed Amount” vs. “Covered or Allowed Amount- Charged or billed amount is of course, the fee charged by the dental office. Covered or allowed amount would be the total amount allowed for that procedure by the patient’s plan. Unless the Doctor has contracted with the carrier to charge only the covered amount, the patient will always be responsible for the difference.
Deductible- This would be the amount that must be paid by the patient, before any benefits can be paid. Usually this applies to “Basic” & “Major” categories, but with some plans may apply to all categories, including “Preventive”. It is best to always collect this amount up front.
Alternate Benefit- This one you will see often. For instance, in the case of posterior composites being allowed as amalgam restorations. Another scenario might be an alternate benefit of a partial denture being given instead of allowing benefits for a fixed bridge or implant.
Frequency Limitation- This is really one to watch. Today many carriers are really getting tricky with this one. In the past plans covered Preventive procedures one time every six months, or twice per calendar year. Now, some are covering twice per 12 consecutive months, plus 1 day. Nothing will frustrate a patient more than being scheduled too soon for their insurance to pay, especially when waiting one day or one week would have resulted in a benefit. Other services besides Preventive are subject to frequency limitations. For instance, there can be anywhere from a 5 to 10 year frequency limitation on replacement of prosthetics. Another area where frequencies often apply is periodontal services. Many plans cover scaling & root planning and/or osseous surgery once every 12 to 36 months.
Maximum Benefits- Each plan has an exact dollar limit to be paid per patient per benefit year. Benefit years can run on the calendar year, or a fiscal year, determined by the employer. If the plan runs on a calendar year that would of course be January 1 through December 31. But if the plan runs on a fiscal year, the dates will vary. This is why it is so important for you to confirm benefits with each plan. Let’s say the plan runs June 1 through May 31 each year, and it is now November 15th. You tell the patient his benefits have maxed out, & he decides to resume treatment January 1st, thinking his plan runs on the calendar year. When the patient resumes treatment in January, you will receive an explanation of benefits saying “plan maximum exhausted”. Needless to say, that patient won’t be happy, nor will the Doctor.
Even though it is the patient’s insurance, if we are going to accept assignment of benefits, we must be aware of important facts such as what dates the plan year runs on. It is necessary for survival!
Waiting Periods- Another biggie! There are often waiting periods before benefits will be paid for certain procedures. This can vary, depending on the plan, from 6 to 24 months. So, if that is the case, and you perform services that are subject to a waiting period, you will not get paid! Again, being familiar with each patient’s plan is the key.
Non - Duplication of Benefits- This means that if the patient’s secondary plan has this provision, they will not pay out any more than if they were the only plan the patient has. This is a very gray area in dental insurance. Insurance carriers have many different names for the way they calculate secondary benefits. My suggestion is to let the patient know you do not accept assignment on secondary benefits, but you will be happy to file the claim to reimburse them directly, once the primary has paid. That way, you are not trying to second - guess what the secondary carrier will do. This is the best way I have found to handle primary/secondary coverage. Of course, this is up to the Doctor and/or Office Manager, as to how your practice will handle.
Dental insurance is a complex, challenging subject. I decided many years ago, not to get mad, but to get with the program! I promise you, it can be mastered. It is ever changing, but it will keep your life at work interesting. And as you become more familiar with it, it will become less stressful. The best part is you can make a difference, for your patient, and your practice.
Written By: Elaine Dickson