Handling insurance is one of the most difficult tasks for dental front offices. Today, this has become all the more complex as in addition to submitting dental procedures to dental payers, dental medical billing also involves submitting dental procedures to a patient’s medical plan. Dental insurance verification services take the pain out of verifying patients’ coverage, streamlines front office operations, reduces claim denials, and boosts cash flow.
Both providers and patients should know that dental insurance is different and separate from medical insurance. In a 2017 NBC article, Dr. Adam C. Powell, president of Payer+Provider Syndicate explains that “the reason dental is separate from medical is that the nature of the risk is fundamentally different as is the deferability of the care.” He points out that unlike medical emergencies that would need to be treated in the emergency room right away, dental problems are not life threatening and can often wait. Unlike medical, dental insurance is not regulated and tends to be very constrained. The annual maximum benefit is not as high as in medical insurance, and there is usually some sort of deductible.
Another difference between dental and medical insurance is that while dental insurance will cover preventative aspects of dental care it does not always cover major dental procedures for adults. The purpose of dental insurance is to prevent dire issues by encouraging regular maintenance. If dental insurance is provided through the individual’s workplace, the employer chooses the plan and what it covers.
Dental eligibility verification helps prevent claim denials. There are several reasons why a carrier might deny payment for dental procedures:
- Deductible: The deductible is the amount of money that beneficiaries have to pay for their care before their insurance kicks in. Some preventive procedures are not subject to the deductible. So in the case of high deductible plans, the insurance will not pay for the dental care unless the beneficiary pays their deductible on applicable services.
- Waiting period: Some insurance carriers will cover certain procedures only if the patient has been in the plan for a certain amount of time, which is called the waiting period. A dental benefits waiting period may last a few months or stretch to a full year, depending on the type of plan and the insurance benefits wording. Waiting period usually apply to fillings and major services. When verifying patient’s dental eligibility, dental practices should check if there is a waiting period.
- Exclusions: Most dental plans have certain services that they will not pay for. For example, cosmetic services are not covered. Exclusions vary among plans.
- Limitations and exclusions: Most dental insurances place have limitations. For e.g., there are restrictions on the number of cleanings that will be covered each year. If the plan specifies a frequency limitation of 2 dental exams a year, the insurance will not pay for the third one. Limitations vary from plan to plan, and a dental insurance verification specialist will read the patient’s plan carefully to find out what they are.
- Exhausted benefits: Dental insurance carriers specify a maximum amount per year that they will pay toward dental care. Once that amount has been paid by the carrier, they will not pay any more until the next benefit year begins. Patients have to bear the cost of any procedure they have after their dental insurance is maxed out.
Verifying insurance eligibility is among the important services provided by a dental medical billing company. Efficient and timely verification of patients’ benefits helps prevent claim denials and saves dental offices save time and money. The various strategies and steps involved in the process are as follows:
- Verifying dental eligibility prior to the patient visit: Verifying patient eligibility and benefits prior to the office visit improves claim accuracy and helps inform patients of their payment responsibilities. Insurance benefits can change and even patients may not be aware of these changes. Submitting claims without proper verification of eligibility is one of the most important reasons for denials. Coverage must be verified for both new and existing patients.
- Verifying returning patients’ coverage a week prior to their office visit: According to a www.dentistryiq.com article, it is essential to verify eligibility for returning or recall patients one week before their appointment. While some carriers cover exams and cleanings twice a year anytime, others cover this service only twice a year. In addition to preventing claim denial, verifying eligibility will allow dentists to inform their patients about any plan limitations well in advance of their treatment.
- Calling the insurance company to get the most accurate information: Reliable dental medical billing companies check patient eligibility and benefits at the insurance carrier’s website and also by calling up the carrier. They will get a complete breakdown of benefits for each patient from their respective insurance carrier. This will ensure that up-to-date, accurate dental eligibility information is available for all patients.
- Checking all eligibility items before claim submission: This includes:
- If patient has coverage and if, in network or out-of-network
- Patient demographics
- Primary and secondary coverage
- Coverage percentages breakdown
- If annual maximum has been met, and balance
- Deductible amount and if applied yet
- Exam and x-ray time/frequency limitations
- Crown frequency
The dental billing services provided by experienced medical billing companies cover patient eligibility verification. These companies help the front office collect all of the insurance information ahead of the office visit. This also saves time and improves patient satisfaction as providers can inform patients about their financial obligations. With efficient dental eligibility verification processes in place, dental practices can ensure a smooth and seamless patient registration experience, minimize claim denials and boost revenue.