Dental insurance changes affect treatment plan presentations
Dental insurance policy guidelines affect the amount of reimbursement made to the dental office for completed procedures and impact the final financial responsibility of the patient.
Clear communication with your patients on dental insurance changes will provide them with much-needed transparency as you present individual treatment plans.
As a result, you may need to update treatment plan consent forms to clearly inform your patients of their financial responsibility.
New retirement packages bundle medical and dental coverage
Newer insurance plans often bundle medical and dental coverage for retirees.
These policies consist of a “cost containment” process, which means that the insurance company limits not only the yearly deductible amount but also the amount of coverage allowed per quarter during the year.
For example, the yearly maximum may be $1000, but only $250 would be covered per quarter of the year.
When addressing a patient with this type of insurance, it is best to present the necessary treatment without compromising the best care for the patient.
Let the patient know that the insurance plan pays $250 per quarter and that you will work with the patient to utilize this amount in the best way possible.
Explain any financing options your office may offer but be sure the patient understands their financial responsibility beyond their insurance benefit.
If a senior patient is inquiring about the viability of such a retirement insurance package, be prepared to share the pros and cons of this type of coverage.
Our senior patients know that it is normal to bundle your home and auto insurance together to get a better rate.
It is not normal, however, to bundle your medical and dental insurance because it can create more out of pocket costs for those services.
Dental codes covered under restrictive timelines
Another guideline change that may impact treatment plan presentations pertains to dental procedures with frequency limitations.
An example of this scenario would be the benefit of only two dental exams within a calendar or benefit year.
A third limited evaluation for a dental emergency or other concern may not be covered by the insurance.
The patient must understand that their insurance may help cover some procedures but only within a specified time frame.
When discussing their treatment plan, always present with the best interests of the patient, but without the treatment being driven by the insurance company.
Patients will see that you are offering all viable options for their care.
The carrier downgrading or changing alternative benefits
The final example of dental insurance changes we’re seeing is how carriers are downgrading or changing procedure codes to an alternative benefit.
Because an insurance company has the ability to change codes to procedures with lesser benefits, patients need to be aware that this policy can or may impact their coverage.
You will want to inform them that the dental insurance company maintains the right to do so, and that they might list certain procedures as being uncovered.
In such circumstances, the patient needs to be aware that they will be financially responsible for any difference in fees.
Additionally, fees not covered by the dental insurance policy will then revert from the insurance company UCR (Usual, Customary, Reasonable) amounts back to the set fees of your dental office.
Here is a sample of what you might use for a patient’s Treatment Plan Consent form:
As a condition of treatment, financial arrangements are made prior to scheduling dental appointments. Amount due is expected at time of service. Dental services are billed directly to the patient(s) and they are responsible for total cost regardless of insurance benefits. We will assist you as much as possible by filing the necessary forms. We cannot render services based on the assumption that they will be paid by your carrier. Your dental insurance company maintains the right to change your treatment reimbursement to an alternative benefit. This may change the final amount for which you are responsible. Under [Arizona State Law, any increase in fees are the responsibility of the patient] *.
**NOTE- ESTIMATE ONLY** Some teeth may have hidden decay, cracks, or affected nerves that may require additional treatment and cost. If this occurs, you will be notified immediately.
I acknowledge receipt of this treatment plan.
*Note: Please refer to your individual state laws when you edit this form
When there’s a gap in coverage
When you receive an EOB (estimation of benefits) showing that the patient owes more than you estimated and collected, we can properly add this difference to the patient ledger by assigning a service code with a description.
You would need to create a special code for each category of the dental procedure codes.
For example, in the case of a fee for a diagnostic procedure, you could use a code D2999.1 to record the difference in the fee between the insurance company’s allowed fee and the set fee of your dental office.
For an endodontic procedure, you could use a code D3999.1; for a periodontic procedure, you could assign code D4999.1, and so on, through your list of service categories.
When you assign a description for this code (required for each) you can base it on the following example:
D2999.1 Ins. Fee Difference
This fee is the patient responsibility per insurance company reasons such as alternative benefit, non-covered services, frequency limitations, or coverage was terminated before services were rendered. The amount is the difference between the insurance company’s UCR rates and the set fees of the dental office.
When something like this happens, I send a copy of the EOB and insurance statement along with a note stating something like:
“Your insurance company has paid their share of your bill. They are making you responsible for the difference in fees. Please see the highlighted area on the attached Explanation of Benefits”.
I then highlight the area of the EOB showing the patient’s remaining balance.
Clear communication around dental insurance changes means happier patients
Helping patients understand their financial responsibility as you present their treatment plans and consent forms will greatly reduce confusion and negative feelings later on.
Because each individual insurance company has its own policy guidelines, please request that patients submit or bring in a copy of their dental insurance plan with them to their appointment.
This proactive step will help you navigate the specific requirements and assist during the treatment plan presentation.
By adding carefully worded phrases into your treatment consent forms, EOB messages and statements, and by placing descriptive service codes into treatment ledgers, you can improve the financial communication that takes place between your office and patients.
Meet the Author
Paula Thomasson, FAADOM, has spent over 30 years doing what she’s always wanted to do: work in the dental industry.
She started out as a dental assistant and has spent the last 20 years as an office manager, receiving her AADOM Fellowship in August 2015. Paula is the President and Founder of the Desert Gold Arizona Chapter of AADOM…Opens in a new window to AADOM chapter page….