With changes in insurance policies and billing guidelines, specific coding requirements, varying and complex reimbursement rates, dental billing is a challenging process. This has led many practices to rely on dental billing services to manage their revenue cycle. Outsourcing dental billing to an expert can ensure comprehensive support for everything from appointment scheduling, patient registration and insurance verification to claim submission, posting insurance payments on a daily basis, and appeals to overturn denials. Such support is important for efficient orthodontics billing, which poses unique challenges due to the specialized nature of orthodontic treatments and the intricacies of insurance coverage.
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Orthodontics, the branch of dentistry concerned with diagnosing, correcting, and preventing irregularities of the teeth and poor occlusion, involves “the use of any appliance, in or out of the mouth, removable or fixed, or any surgical procedure designed to redirect teeth and surrounding tissues.”
There are three categories of orthodontic treatment: Limited, Interceptive and Comprehensive. The ADA CDT code book defines these categories as follows:
- Limited Orthodontic Treatment – This is defined as orthodontic treatment with a limited objective, not involving the entire dentition. It may be directed at the only existing problem, or at only one aspect of a larger problem.
- Interceptive Orthodontic Treatment – This refers to procedures to lessen the severity or future effects of a malformation and to eliminate its cause. It can be considered an extension of preventive orthodontics that may include localized tooth movement. Such treatment may occur in the primary or transitional dentition.
- Comprehensive Orthodontic Treatment – This involves treating the dentition as a whole. Treatment usually, but not necessarily, uses fixed orthodontic appliances or braces. Comprehensive Orthodontic Treatment may incorporate more than one phase of treatment, with specific objectives at various stages of dentofacial development.
Orthodontic treatments often require an extended period for completion, typically spanning several months to multiple plan years.
Billing for Orthodontic Treatments
Billing for orthodontic services refers to generating and submitting claims to insurance companies for orthodontic services. It requires completing several steps correctly to ensure accurate reimbursement and compliance with healthcare regulations. This includes coding and documenting the treatment plan, followed by the submission of the claim to the insurance company for reimbursement. Let’s take a look at key steps involved in billing for orthodontic services
- Assigning Orthodontic Codes: There are different orthodontic codes for treatments performed in the primary, mixed, adolescent, and adult dentitions. Codes are also defined by whether the treatment is limited, interceptive, or comprehensive. Submitting the right dental codes to insurance companies is essential to receive proper payment for work performed. Here are the codes for common orthodontic treatments:
- Orthodontic retainers – D8220-Fixed appliance therapy, D8210¬–Removal appliance therapy, and D8680-Orthodontic retention
- Limited orthodontic treatment – D8010-Limited orthodontic treatment of the primary dentition; D8020-Limited orthodontic treatment of the transitional dentition; D8030-Limited orthodontic treatment of the adolescent dentition; D8040-Limited orthodontic treatment of the adult dentition
- Comprehensive orthodontic treatment – D8070-Comprehensive orthodontic treatment of the transitional dentition; D80-Comprehensive orthodontic treatment of the adolescent dentition; D8090-Comprehensive orthodontic treatment of the adult dentition
Multiple phase treatment plans would require the use of comprehensive orthodontic procedure codes. Choosing the correct CDT and diagnosis codes requires extensive knowledge of dental procedures and the ability to accurately document the services rendered. CDT codes are sometimes redefined and clarified, and new codes added from time to time to define new procedures. Incorrect coding can lead to claim denials or underpayment, requiring additional time and effort to rectify.
- Patient Registration and Insurance Verification: The patient must be eligible for orthodontic benefits, and so the first step would be determining eligibility. As orthodontic benefits differ significantly from policy to policy, it is essential to contact the patient’s insurance carrier for dental insurance verification and coverage. Moreover, some dental plans offer benefits only for children, while others cater to adults.
Benefits verification is carried out before the patient’s office visit. Information verified would include: the name of the insured (subscriber), date of birth, social security number, or other identification number; the name of the patient or beneficiary; the insurance company’s name and phone number; and the policy number. The insurance verification specialist will contact the insurance company to find out the lifetime (or sometimes annual) maximum, percentage of the fee paid by the carrier, copayment, and deductible, and limitations such as age and dependency status.
Checking the eligibility or benefit information prior to the patient’s consultation allows practitioners to provide a more organized consultation, and also helps patients evaluate their financial options more easily and quickly.
- Estimation of Patient Responsibility: This step involves calculating the estimated patient responsibility, including deductibles, co-payments, and any non-covered services. The provider should communicate this information to the patient, and discuss payment options and financial arrangements with them.
- Coordination of Benefits (COB): If the patient has dual coverage (e.g., both dental and medical insurance), coordination of benefits is verified to determine which insurance is the primary payer. Determining which insurance plan is primary and which is secondary requires careful evaluation of policy rules and guidelines. After identifying the primary and secondary carriers, claims are submitted in accordance with the specific guidelines for billing each health insurance plan.
- Claim Submission: Dental billing service providers submit orthodontic claims electronically with all the information necessary to help the payer determine benefits quickly. Aetna spells out the information to include as: banding date; number of months of treatment; assignment of benefits information; ADA code; total case fee; primary insurance provider explanation of benefits (if COB is necessary), and prior insurance carrier information, including deductible, coinsurance/copay, maximum and amount paid to date (if patient is continuing active treatment). Knowledge about each insurer’s claim submission deadlines is crucial to prevent denials.
- Appeals Process: In case of claim denials, the billing department should follow the appeals process outlined by the insurance provider. Additional documentation or clarification to support the claim should be submitted as needed.
- Record Keeping: Dental practices should maintain thorough and organized records of all billing and claims-related activities, including documentation of patient communication, claim submissions, and payments received.
Treatment planning and proper documentation is also integral to the billing process. After developing a treatment plan based on the patient’s needs, including the type of orthodontic appliances, duration of treatment, and associated costs, orthodontists need to ensure thorough documentation of the treatment plan, including clinical notes, and diagnostic records
Completing all these steps correctly can be challenging. Additionally, efficient dental billing requires:
- Understanding the intricacies of different insurance plans, their policies, and the associated regulations
- Staying updated with codes and changes in insurance policies and billing guidelines
- Being knowledgeable about the fee schedules of different insurers and negotiating contracts that are favorable to the practice
- Adhering to healthcare regulations and compliance standards, including those set by the HIPAA and other relevant laws.
Outsource Dental Billing – Leverage Expertise
Outsourcing dental billing is a practical strategy to manage the complex billing process. An experienced dental billing company will have experts on the job who are trained in coding, claim submission, and insurance reimbursement. They stay updated with the latest codes, industry changes and regulations, resulting in more accurate and efficient billing. Outsourcing allows dental practices to tap into this expertise, improve their billing processes, and ensure faster, accurate reimbursement.
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