Misunderstood and overlooked limitations spelled out in preferred provider organization (PPO) network contracts hurt the bottom line in practice revenue every day. Submitting a claim for covered benefits and receiving a check for services rendered is the expected outcome. However, some situations interrupt this flow and are important to know before performing any services.
Two documents are needed to manage payment cycles for insurance reimbursement: the summary plan description (describes covered benefits) and the plan document (policy provisions defining limitations to covered benefits). The information in the plan document is provided to the patient but not to the practice, so many busy dental practice workers fail to see the print beyond the general benefits of the summary plan description.
The summary plan description is the tool used to estimate insurance payments and coinsurance, or the patient portion of treatment plans.
Why you need this information
The plan document, also known as the insurance contract, is between the employer and the insurance company. It contains essential details specific to the limitations and exclusions of the plan. It is not provided to the practice by the insurance company; however, the patient can get it. It is vital to have this information on PPO network policies for the following reasons:
- Better treatment plans: Insurance coordinators can present a more accurate treatment plan for a patient if they have a full understanding of the plan's covered benefits, limitations, and exclusions.
- Collection at the desk: The office manager/insurance coordinator can collect coinsurance at the time of service, eliminating many debt collections. Collection attempts at the end of service cost the practice more money in statements, as well as time spent on the phone chasing debtors and/or outsourcing to collection agencies.
- Patients choose more treatment: Patients are happier when the practice is confident in what to expect from the insurance companies and the insurance claims get paid more quickly. Patients are more apt to choose additional treatment when the claims pay without delays or denials. Before embarking on a series of treatments, the patient must be fully informed of any limitations or exclusions to his or her insurance plan.
Common exclusions that cost the practice revenue include the "missing tooth clause." The clause defined does not cover the replacement of teeth extracted before the insurance coverage start date. The clause refers to the "initial placement" of a prosthetic and not the replacement of an "existing" prosthetic (subject to frequency limitations). In some policies, the "missing tooth clause" terminates after the patient has paid on the policy for a set period, which is a reason to read the plan document.
Frequency limitations affect almost all procedures performed in a dental practice. The frequency limitation defines the number of procedures allowed within a stated period. A standard prophy, code D0110, may be covered by one plan twice in a calendar year; by another plan, once every six months to the date; or by yet another plan, just once in a calendar year.
If the practice is contracted with the PPO and provides the service outside of the frequency limitations, the patient cannot be billed. For example, say a patient calls to make an appointment for a routine cleaning and evaluation. The date is set for the first available time, and the receptionist does not check the patient's insurance frequency limitations. The claim is denied for payment for both the evaluation and the prophy because the date of service was two days before coverage was payable. The practice cannot bill the patient because of the contract provision.
To ensure cash flow from dental insurance claims, make sure your team understands the importance of checking the policy provisions for all contracted insurance plans.
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