Ascertaining a patient's dental benefits should not be a convoluted issue, but it seems to be a problem for many offices.
Sheri B. Doniger, DDS.
Many years ago, I worked for a dental benefit company (who shall remain unnamed). This gave me an insight to the mystery of dental plans: from accurate and complete information on dental claim forms to basics on what is and isn't covered.
In a nutshell, we know that 50 different dental benefit products may be available for each individual benefit company. If a patient comes in and has a major (or lesser known) dental benefit company listed on the insurance card, we are not able to surmise his or her level of benefit.
Company ABC has amazing coverage for 80% of their participants. If our patient presents with this ABC plan, she or he may be on one of those schedules that pay less than $20 for a dental exam.
But, let's go back to the patient's initial visit. How do we find out what is and isn't covered in each individual plan? And, more significantly, is this patient covered by this plan to visit your office at this time?
Ask for information
To begin your benefit quest, it is as simple as asking patients for basic information or confirming data they may have already presented. We always request a copy of patients' dental benefit card, front and back.
“How do we find out what is and isn't covered in each individual plan?”
Yes, you think this is simple, but some companies have different addresses or contact numbers for different products in their lines. The other few pieces of the puzzle are the patient's identification number (located on the card), date of birth, and the head of household on the plan. Some plans request the Social Security number for further identification. If the patient is not the policyholder, she or he will have to give you the Social Security or identification number of the subscriber.
We created a straightforward form to fill in when calling the dental company. This form allows you to talk with a representative with a list of questions already prepared. Knowing the basics of in- and out-of- networks to the number of dental preventive services a year will help you better to discuss your patient's expected benefits.
We included several items on this form from my many years at the dental benefit company. Some plans allow for two preventive services per year, no matter the date. Some require six months plus one day to comply with their twice-a-year program.
As we include fluoride varnish for every patient, we would like to know if it is covered. Surprisingly, some progressive plans do pay for a yearly adult fluoride application.
Many practitioners ask me why a limited or emergency examination is not covered. Some plans only offer two examinations of any type, be it routine or emergency. If a patient started with your practice as an emergency then completed the comprehensive evaluation, an additional examination within the same year most likely will not be covered.
Waiting for treatment
On occasion, patients will need to wait for treatment. Some plans cover preventive services only for a specific period. Some make patients wait for six months to a year for restorative treatment.
We also have asked insurance company representatives to define major treatments. Some include periodontics, endodontics, and oral surgery in this category, but some do not. It is important to know the levels of coverage and their descriptions as there is no universal definition.
Also, some dental companies will pay for three preventive services a year if the patient has a history of diabetes. This needs to be certified by the patient's physician, but, if available, it is a wonderful benefit to the patient, as well as for our ability to monitor the patient's oral conditions. If your patient has diabetes, it may be incumbent on you to question the representative regarding the plan's limits on preventive wellness visits.
Once in a while, we receive voice prompts to fax an eligibility and benefits summary. We appreciate this documentation and include it in the patient's chart for future reference. For the rest of the questions that may arise, we do need to contact a live representative. We may need to wait five to 20 minutes to speak with someone, but the benefits are greater than our frustration at a long wait time.
Having this information ready for the new patient or a patient of record who has changed dental plans may be the difference between the patient keeping a scheduled appointment and canceling it.
Sheri B. Doniger, DDS, practices clinical dentistry in Lincolnwood, IL. She is the immediate past president of the American Association of Women Dentists. She has served as an educator in several dental and dental hygiene programs, has been a consultant for a major dental benefits company, and has written for several dental publications. You can reach her at firstname.lastname@example.org.
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