Based in the U.S, Outsource Strategies International (OSI) is a professional and experienced medical billing and coding company in providing medical billing and coding services for medical practices, clinics, hospitals and individual physicians.

In today’s podcast - Amber Darst, our Dental Insurance Coordinator discusses about dual coverage in dental insurance.

Hey, this is Amber Darst, Dental insurance Dental Insurance Coordinator for Managed Outsource Solutions. As we all know, understanding dental insurance can be quite a challenge. There are several confusing aspects involved and the one that I want to hit on today is “Dual Coverage”. It can get quite tricky. When you are speaking of dual coverage, this is pertaining to when a patient is covered by more than one insurance plan.

00:31 - Dual Coverage – Advantages

So, the advantage for the patient of having dual coverage is that it can fill the gaps in coverage that occur when a few different things happen. First, when the individual's primary policy’s annual spending limit has been reached, or when a plan does not provide coverage for necessary or desired dental treatments, or even just to pick up that insured amount that the primary didn't pay, oftentimes leaving the patient with zero out-of-pocket cost. So dual insurance definitely helps people maximize their benefits.

01:04 - Dual Coverage – What it means to be primary and secondary

Now, when it comes to figuring out what is primary and what is secondary, that’s when it gets a little hazy. Generally, the primary plan is the plan that the patient themselves is enrolled in, and the secondary plan is the one that covers them as a dependent. Once the primary plan has paid what expenses it should pay as determined by the coordination of benefits or COB provision, the secondary plan then can be used. And for adults, the primary plan is the one in which the person is enrolled typically through his or her employment and then their spouse’s plan would be considered secondary. If an individual has a plan through their current employment as well as a retiree plan, the plan that is through current employment would be the primary. And for dependent children, primary coverage is usually based on which parent’s birthday falls earlier in the year. In the event of a divorce or remarriage, court orders may state which parent has primary responsibility.

So, it is up to the dentist’s office to determine which plan is primary before the patient’s appointment. Failing to do so may result in improper billing and a wrong distribution of funds. It is quite time consuming to fix these mistakes once the clients have cleared their payment.

02:29 - Coordination of Benefits (COB) - How Insurance Pays

Now, when a patient has dual coverage, plans will coordinate the benefits to avoid over-insurance or duplication of benefits. Like I have already covered, claims are first sent to the payer that offers the plan designated as primary. That plan should pay its normal benefits, regardless of any other insurance plan or additional coverage. From there, once sent to the secondary carrier, it is up to the secondary guidelines on how they proceed with their payment.

02:59 - Types of COB Policies

There are several different COB policies that determine how the patient’s coverage is met -

03:05 – Traditional – First, would be traditional. The traditional COB policy allows the beneficiary to receive up to 100 percent of dental treatment expenses from a combination of both the primary and secondary plans.

03:19 - Non-duplication COB – Then, there is non-duplication COB. In this case, if the primary plan paid the same or more than what the secondary plan would have paid if it had been primary, then the secondary plan is not responsible for any payment at all. If the primary plan pays less than the secondary carrier allows, then secondary plan will pay the difference between the primary plan payment and the allowed amount of the secondary plan.

03:49 - Maintenance of Benefits (MOB) – Then we have Maintenance of Benefits (MOB). This arrangement reduces covered charges by the amount of the primary plan has paid, and then applies the plan deductible and co-insurance criteria. As a result, the plan pays less than it would under a traditional COB arrangement, and the beneficiary usually has to share some of the cost.

04:10 - Carve-out – And last we have, carve-out. In this coordination method, the normal plan benefits that would be paid are first calculated, and then this amount is reduced by the amount paid by the primary carrier.

So by coordinating benefits, the primary and secondary health insurance companies use both health insurance plans in a way that avoids a duplication of benefits while still providing the patient with the coverage to which they are entitled.

04:37 – Tips for Filing Claims

Here are a few tips for filing claims and annoying the payments for primary and secondary payment plans -

  • Both primary claims and secondary claims must be filed. Always file both, even when you think that secondary would not be taking up any extra charges.
  • Also, when filing, the American Dental Association (ADA) encourages providers to bill their full practice fee on all dental claims.
  • Write-offs should not be posted until all plans have been paid.
  • If the dental office receives more than the practice fee, it must refund the insurance company.

If the total paid by multiple plans is less than the lowest contracted fee, the patient has to pay the difference between the lowest contracted fee and the total paid by the dental plan. If the dentist is not contracted with any of the patient’s plans, the patient is responsible for the full practice fee as submitted on the claim form.

05:36 - COB Rules

COB rules for insured plans are generally defined by state insurance laws. Each insurance follows a different set of rules and one insurer may require prior authorization for certain services, while another may not. The best option for providers is to rely on an experienced dental billing company to submit accurate claims which would ensure you get paid quickly.

And that’s it. I hope this helps, but always remember that documentation and a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed. Thanks for listening in.