The Importance of the Dental Insurance Breakdown Form [Part 3]
by Ashley Bond
In part 1 and part 2 of the importance of the dental insurance breakdown form, we discussed the three reasons why accurate insurance breakdown forms are so important and what each section of the breakdown form means.
Today, we’re going to get into the meat of the insurance breakdown form and discuss the preventative, basic, and major services.
Percentages for preventative, basic, and major services
The standard for most dental insurance companies (and what usually auto-populates in your dental software) is coverage levels of 100%, 80%, and 50%.
But nothing is ever quite standard with insurance companies. So always check!
Double-check what this plan includes under preventative, basic, and major categories.
For instance, some plans cover diagnostic x-rays under basic and some plans cover perio under major. Each plan is different, so these small details are important for accurate treatment estimates.
Let’s get into the specific examples.
Exams
How many are covered per year? Usually, this coincides with prophys per year, which we will discuss in a bit.
FMX/panos
Typically, these two codes are interchangeable. Especially for new patients and perio patients, you want to know how often this patient is eligible for a full set of x-rays or a panoramic x-ray.
Most dentists will order an FMX or pano on new patients and then again every 3-5 years, depending on their oral health history and needs.
For a patient that’s only covered for a full mouth series once every five years and you take one every three, they will have to pay out of pocket. This is information that you, the dentist, and the patient will want to know ahead of ordering the films.
BWX
These x-rays are typically taken once a year.
You need to know if the patient’s plan covers them at that same frequency; I’ve seen companies only cover them once every two years. Sometimes it’s once every 12 months to the day.
So it’s important to make sure the appointments are scheduled correctly or make the patient aware of their out-of-pocket expenses.
Prophy
This is what most of our patients come in for, right? Their dental cleaning.
The last thing we want is to schedule our patient for their second cleaning of the year and realize 30 days later that insurance didn’t pay because they cover prophys once every six months to the day, but this person came in one day early. It hurts; trust me, I know.
This is why we ask the right question ahead of time.
What’s the frequency of cleanings during the year? Typically, it coincides with the frequency allowed for exams.
Perio maintenance
This code is a free-for-all with insurance companies. Some cover it at 100%, some at 80%, and others not at all.
We need to know what percentage this procedure is covered at for our perio patients and how many are allowed each year.
Again, insurance shouldn’t dictate the treatment that’s prescribed. If a patient needs four perio maintenances a year, nothing changes that.
However, we need to know to collect for two of them and not wait to chase the money down after the appointments insurance doesn’t cover.
SRP
For scaling and root planing, it’s important to find out if we can do four quads in one day.
Typically, offices like to separate these out, but we have had patients ask if they can just get it all done in one sitting.
I have also seen dental insurance policies force patients to wait at least seven days between SRP visits. Their guidelines for that plan are something we need to know for our patients.
Composite fillings
We all know that amalgam is no longer the go-to material for restorations, yet dental insurance doesn’t reflect as such.
A lot of times, companies will downgrade posterior teeth to amalgam fees, and the patient is responsible for the difference.
That doesn’t mean we change our treatment recommendations, but we do need to let the patient know that their insurance will downgrade their coverage to the cost of a silver filling. We can then explain that our office does not place silver fillings, so there will be a difference in the fee we collect and the portion that is due once we get insurance back. I advise patients that this is usually $20-$50 per tooth.
Crowns
Speaking of downgrades, there are also insurance companies that downgrade crowns to another type of restoration.
That’s why it’s important to note this question when asking about crowns specifically.
We also want to know if crowns are paid on the prep or seat date and if there is a replacement clause.
While the typical replacement clause is five years, I’ve come across plans that have a 10-year replacement clause on crowns. This means if a patient is in need of another crown before the ten years is up, their insurance will not cover it.
Guards
If your office recommends custom guards for your patients, then you need to know if it’s a covered benefit.
A lot of times, it is an out-of-pocket expense, so we want to go over the full treatment plan with them from the beginning.
Another thing to check is if guards are covered for bruxism or only after surgery. If there is 80% coverage via the fax back form, I would always make sure I am 100% confident that it’s due to bruxism.
Orthodontics
Lastly, if your office provides adult orthodontics, then you want to get coverage for adults specifically.
On top of that, if you’re in-network, you need to find out if you can charge the difference between your contracted amount and the upgrade charge for clear aligners.
I would also ask if the carrier will cover the cost of orthodontic retention. You need to know if performing orthodontic work for your patients is worth it financially for your office, especially with the costly lab fees.
There you have it! We were able to break down the dental benefits breakdown form.
As you can see, there is a lot that goes into getting an accurate and detailed estimate for your patients. Not only does this enhance your patient experience and boost your collection rate, but it also widens your knowledge every time you get a detailed breakdown.
Don’t miss out on any of these vital questions, and take the surprise out of your patient’s dental bills.
If you’re ready to outsource your dental billing needs to an expert, view our monthly packages at www.bonddentalconsulting.com/dental-billing… This text opens a new tab to the official website….
Meet the Author
Ashley Bond is the founder of Bond Dental Consulting… This text opens a new tab to the official website…, a company specializing in remote dental billing, A/R, and dental consulting.
Her passion is to help practices stress less, collect more, and get back to what’s really important: the patient relationship.
Ashley has over a decade of experience in the dental field, beginner her career at her father’s dental practice. There, she learned the ins and outs of everything the business entails. She has played many roles, including treatment coordinator, office manager, marketing manager, and insurance guru.
Get all the latest dental tips and tricks on her weekly podcast, “Quick Bites for your Dental Office… This text opens a new tab to the podcast’s web page…,” and follow her on Instagram (@bonddentalconsulting)… This text opens a new tab to her company’s Instagram… and Facebook… This text opens a new tab to her company’s Facebook….
