Dental eligibility verification is the essential process of confirming a patient’s eligibility for dental insurance benefits. This involves verifying the status of their coverage, including active policies and any necessary prior authorizations for a wide range of dental procedures, from routine cleanings to complex surgeries. This crucial step ensures that both the patient and the dental provider have a clear understanding of the insurance coverage and any associated requirements before treatment begins.
Dental insurance verification services are provided by dental billers who have previously worked in dental offices, specifically in insurance verification.
Insurance verification is carried out before a patient’s appointment, aimed at documenting their current insurance coverage and understanding the benefits they are entitled to. This process ensures that both the patient and the healthcare provider have a comprehensive understanding of the patient’s insurance status, allowing for smoother and more informed healthcare interactions.
The effectiveness of eligibility verification is the primary determinant of successful billing. In essence, health insurance verification involves the process of contacting an insurance company to ascertain whether a patient possesses active coverage and to validate the legitimacy of the patient’s insurance claims. This crucial step ensures that healthcare providers can accurately bill for the services rendered while also preventing potential issues related to insurance coverage.
Dental Insurance Verification – Some Important Considerations
The following points are examples of what to verify when calling to collect the patient’s benefits:
Determine the effective date of the patient’s benefits
This specifies when the patient’s insurance coverage becomes active. If the patient has recently acquired a new insurance plan, it’s important to verify whether their benefits have taken effect yet, as there may be a waiting period before coverage begins. This is a critical initial step that should be checked first and foremost.
Verify their plan’s maximum coverage limit
The insurance maximum represents the total financial cap that the insurance provider will contribute towards the patient’s dental care over a 12-month period. It’s essential to examine this, particularly if the patient is approaching this limit.
Exceeding the maximum will result in the patient incurring higher out-of-pocket expenses, and it is crucial to have a conversation with the patient about this possibility.
Ascertain the standard coverage percentages
Both the dental practice and the patient should have a clear comprehension of how much the insurance will contribute toward the intended procedure. Coverage percentages typically fall into categories of 100%, 80%, or 50% from the insurance provider.
It’s important to educate the patient on their coverage and what portion of the costs they will be responsible for. Stress the term “estimation” when informing them about their expected out-of-pocket expenses, ensuring they understand that the final amount may vary.
Determine the patient’s deductible amount
The deductible can significantly impact the patient’s financial responsibility. It represents a fixed amount that the patient is required to personally cover for dental expenses before their insurance provider starts contributing to the plan’s benefits.
Typically, insurance plans feature both an annual deductible per individual and a family deductible. Unfortunately, many patients may not fully grasp the intricacies of their insurance coverage. Hence, it is essential to communicate and clarify their expected financial obligations during the insurance verification process. This not only fosters trust with the patient but also serves to prevent unexpected bills upon completion of their treatment.
Verify if there have been any benefits previously applied
Is the patient’s utilization of most of their annual benefits already apparent? In such a scenario, it’s advisable to communicate this to the patient and, if feasible, consider scheduling their treatment around the time when their insurance plan renews for the year. It’s important not to let insurance benefits dictate the treatment provided, as postponing treatment could potentially lead to more extensive and costly procedures in the long term.
Naturally, the urgency of the required procedure plays a role. Nevertheless, it’s beneficial to offer the patient the option to be aware of the potential costs if they have already made use of their insurance benefits.
Exclusions and clauses pertain to specific regulations or conditions outlined in the patient’s insurance plan agreement. This fine print should not be overlooked, as it can significantly influence the extent of the patient’s coverage through their benefits.
The following are some of the conditions to be checked for verification:.
Frequency
Dental insurance plans often impose limitations on the frequency of certain treatments. For instance, a patient’s plan may only cover two dental cleanings per year. If you observe that the patient is scheduling a third cleaning and their insurance plan restricts them to two, it’s crucial to convey this information to the patient. This ensures they are aware that the additional cleaning won’t be covered by insurance, allowing them to make an informed decision regarding their treatment.
Age Restrictions
Insurance plans typically do not provide coverage for individuals aged 26 and above under their parent’s policy. It’s important to verify whether the patient has reached the age at which they are no longer eligible for coverage through their parent’s insurance.
Additionally, certain procedures may have age-related limitations. For instance, orthodontic benefits may be applicable only until the age of 18, and coverage for fluoride treatments may extend to individuals aged 16 and below. These age-related restrictions can affect the availability of insurance benefits for specific treatments.
Substitution Provision
In dental insurance, a replacement clause specifies that the insurance provider will not cover the cost of replacing certain dental procedures, such as a lost retainer or a filling replacement within 24 months of the initial placement.
For instance, if your patient received a bridge just four months ago and now requires a replacement, their insurance policy may stipulate that replacement coverage is not available for another 5 to 10 years.
If a patient contacts you seeking a new bridge, and after verifying their insurance, you identify this replacement clause, it becomes essential to schedule the replacement in accordance with the insurance policy’s guidelines.
Tooth Absence Provision
When a patient experiences tooth loss and requires treatment, it’s essential to conduct dental insurance eligibility verification with a focus on the “missing tooth clause.” If the patient lost the tooth before their insurance coverage commenced, the insurance provider may not cover the necessary treatment for the missing tooth.
However, in cases where the patient’s employer remains the same and transitions to a new insurance carrier, there may be grounds for an appeal to secure coverage for the treatment.
Waiting Period
A common observation regarding many of these exclusions and clauses is their reliance on timing. During the insurance verification process, it’s essential to investigate waiting periods since they denote the specific time frame during which certain dental procedures become eligible for coverage by the patient’s insurance.
Typically, waiting periods apply to restorative or major dental procedures, but it’s a prudent practice to verify this information regardless.
In the event that the patient has recently enrolled in a new insurance plan, there could potentially be a waiting period that temporarily prevents them from accessing their insurance benefits.
Downgrades
While all these regulations and conditions hold significance, it’s crucial that the patient is informed about a more cost-effective treatment option if it exists. This is where a “downgrade” comes into play, as insurance plans will cover the least expensive procedure among multiple acceptable options. It’s a matter of ensuring the patient is aware of their choices and the associated costs.
If the patient’s insurance is amenable to covering a downgrade, it’s essential to make a record of this during the insurance verification process and present the patient with that alternative. In certain in-network plans, there may even be a requirement for a downgrade document that the patient needs to sign, signifying their consent to opt for the less expensive treatment option.
More Dental Insurance Verification Tips
Here are some additional quick insurance verification tips to consider as you navigate through this checklist:
Always obtain a comprehensive benefit breakdown for each new patient. Similarly, when there are changes in their insurance, ensure that you acquire an updated full breakdown. Additionally, it’s vital to verify the coverage details for all scheduled appointments 2-3 days in advance.
It’s worth noting that even within a family sharing the same insurance plan, the full breakdown may differ due to variations in remaining deductibles and maximum benefit amounts. However, the coverage breakdown, including percentages and exclusions, tends to remain consistent.
For patients under the same group number, the coverage breakdown is generally similar, but it’s crucial to double-check the remaining deductible and maximum benefit amounts. This becomes particularly significant if the patient has been referred for specialized dental procedures, or if you are a specialist, coordinate with the referring general dentist to ensure there are no outstanding claims to prevent underestimating costs.
To facilitate accurate estimates, regularly update the remaining deductible and maximum benefit amounts within your practice management software.
By following these insurance verification tips, you can enhance the efficiency of the process and provide a higher level of service to your patients.
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Amber Darst is our Solutions Manager in the Healthcare Division, Practice and RCM. With a rich background in dental services, her expertise ranges from insurance coordination to office management.