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Chapter 36

Chapter 36. Dental Insurance. Dental Insurance. Large portion of accounts receivable. Increases access to dental care. By reducing cost for the patient Not designed to pay entire cost of treatment. Patient is responsible for the balance. Insurance Terminology. Insured aka subscriber

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Chapter 36

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  1. Chapter 36 Dental Insurance

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

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

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

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

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

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

  8. Dual coverage • 2 carriers providing benefits for one pt. • Ins. through employer: primary Ins. • Ins. through spouse: secondary Ins. • Primary pays the usual fee. • 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.

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

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

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

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

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

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

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

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

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

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

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