Chapter 36 Dental Insurance

n Large portion of accounts receivable. n Increases access to dental care. –By reducing cost for the patient n Not designed to pay entire cost of treatment. n Patient is responsible for the balance.

Insurance Terminology n Insured –aka subscriber –person who represents the family –usually employee earning the benefits. n Beneficiaries –someone eligible to receive benefits under a plan –Includes: insured, spouse, and child(ren).

Insurance Terminology n Children –a dependent who does not exceed the age as designated in the Plan. n Until 18th b-day n Through age 18 (until 19th b-day) n Until age 21 n School “full time” until 21 n permanently disabled. –Determined by the Ins. Co. and the plan.

Insurance Terminology n Patient = person receiving the Tx. n Carrier = Insurance company n Deductible = $ paid by pt. Before insurance company pays. n May be yearly n Lifetime n Dual coverage = coverage by more than one insurance company.

Insurance Terminology n Plan = is the insurance contract. n Benefits booklet = includes all plan info including: n Features = what it pays for n Exclusions = what it won’t pay for. n Maximums = the most it will pay for tx. n Restrictions = will pay for amalgam not composite on posterior teeth. n Limitations = 5 year replacement rule.

Insurance Terminology n Provider = dentist (could be hygienist or assistant) who performs the dental service (tx). n Schedule of benefits = list of specific amounts a carrier will pay towards the cost of covered treatment. –Not related to the dentists Fee Schedule. n Dr’s list of prices for specific treatment/procedures. n Pt. pays difference.

Dual coverage n 2 carriers providing benefits for one pt. –Ins. through employer: primary Ins. –Ins. through spouse:secondary Ins. n Primary pays the usual fee. n Secondary pays the balance. –Coordination of benefits happens. –Make sure NOT to pay more than 100% of cost of treatment. –Not all insurance plans coordinate. Important to check first.

Dual coverage n Child(ren) –Birthday rule. n Used when child(ren) are covered under more than one plan. n Parent w/ B-day first in the year, = primary ins. parent w/ b-day later in the year, = secondary ins.. n Does not matter if the parents are married, separated, divorced. Only if dual coverage. n Divorce decree or legal document can override this ‘rule’.

Dental Coverage n Benefits available. –? How do you know? n Ask the pt.? n Maybe n Ask the Doctor? n No, not a clue. n Guess? n Might work. (usually leads to an upset pt.) n Call the Ins Company……..??? n Now we are headed the right direction.

Dental Coverage n Hey….lets pre-authorize the treatment before we get started. –aka predetermination of benefits –akapre-treatment estimate n Tx plan to the Ins co. n Ensure they will pay for Tx n How much they will pay. n DONE BEFORE TX.

E.O.B. n Explanation of Benefits –Sent to the office and pt. n Explains what was paid for. n What wasn’t n Why n Date of Tx n Provider. n “THIS IS NOT A BILL”

E.O.B. n Claim Accepted –Ensures payment from Ins Co. –Will bill Pt. for balance. –Big part of Accts. Receivable. n Claim form correct n X-ray sent n Narrative provided n Remaining benefits $ n Claim Denied –No payment from Ins. Co. –Pt. is responsible for entire balance. –Why? n Elective vs. Function n 5yr replacement rule. n Need X-ray n Wrong tooth # n CDT Code #????

CDT Codes n Current Dental Terminology –Aids in submitting claims –5 digit code. n Each code is for a very specific Tx. –Preventative –Restorative –C + B –Specialties. n Double check codes before submitting claim!

Types of Insurance n Fee-for-service. –Very Common. –% paid based on: n Plan –Preventative (100%) example –Restorative (80%) example –Major (C+B) (50%) example n Deductible met? n Tx given.

Types of Insurance n HMO: Health Maintenance Organization –Usually a co-pay…No deductible n Can only go to “their” office / clinic. –All services in one location –Lots of locations –May see different Drs. Each visit / appt. n PPO: Preferred Provider Organization. –Drs. sign up w/ Ins. Co –Ins. Pays higher % for member doctors. –Pays lower % for non- member doctors. n Pt’s have more options n Pt’s can see same doctor w/ different Ins.

Types of Insurance n Capitation n All Pt’s must go to contracted Doctor. n No choice for Pt. n Dr is paid: –Flat fee –Based on # of pt’s –NOT Tx given. –Pt’s may get minimal Tx. n Medic-aid/care –Government provided Ins. n Pays lower rate n Dr’s must accept fee n Cannot chg. Pt. the difference. n Not commonly accepted because of the lower fee schedule.

Closing n Insurance is a big part of accounts receivable. n Understanding how it works is an important part of your job. n Pt’s. are relying on you to explain “it” to them. n When in doubt, ask for help. n Any questions?