The Role Pretreatment Estimates Play in Your Front Office
When a treatment plan is established by your dental provider for your patient, sending the treatment details to their insurance carrier for a detailed response of their estimated benefit payout can provide a wonderful tool for clear communication when setting the patient up for the treatment to be rendered and what they will likely owe.
Concerns of Front Office Teams
I have been leading front office teams in various dental offices for years. In most cases, an overall concern of most front office teams is, “How do we always know how much to collect for the patient’s portion on the day of service if we don’t always know what their insurance policy will pay?”
While a pretreatment estimate received back from a patient’s insurance policy is not a “guarantee” of payment after the actual service(s) are rendered, it is an additional avenue to work from when collecting from the patient on the day the service is rendered.
Insurance Disclaimer
An insurance company will generally always list a disclaimer stating that there is no guarantee of payment.
Nonetheless, I have found that it is a good habit to develop with teams, especially when a patient’s visit might exceed $750.00, and include any major services such as crowns, prosthodontics, periodontal needs, orthodontic treatment, etc.
Avoiding Misunderstandings
Unless your team is meticulous about pre-checking a patient’s benefits, often things such as waiting periods or a missing tooth clause that may be attached to the policy could cause what you “thought” the patient’s portion would tally up to be to actually zero if either or even both of the above to items come into play.
While we all know that patients should be definitely advised when presenting any treatment plan to them that they are ultimately responsible for all fees regardless of whether their insurance plan pays out any benefits or not, a previously healthy and long-term relationship with a patient can be tarnished if they were expecting their plan to pay against their treatment but in the end, the insurance pays nothing because the office failed to advise them of waiting periods or other clauses attached to their coverage.
Submission Process
Often, when a pretreatment estimate is submitted to an insurance company requesting their coverage breakdown, you send in the x-rays and/or photos along with a narrative stating the necessity of the treatment that the treating dentist advises for the patient. The submission of these items prior to the treatment being rendered will often allow the insurance company to respond back to the office if they feel that a tooth doesn’t warrant the need for a crown and could be restored with a filling….or if they feel like the teeth that would anchor a partial, for instance, are not stable enough periodontally to retain the partial.
It is more likely that the treatment will end up being allowed by the insurance company by responding back to the insurance carrier’s initial pretreatment denial with a more indepth narrative from the dentist explaining his educated opinion on the matter or sending in additional information, such as improved oral hygiene history or lack of any teeth mobility, etc. than it is to have already rendered the treatment and they deny any benefits because of that reasoning.
Benefits of Pretreatment Estimates
I have found that sending in pretreatment estimates to insurance companies is a practice-building tool that fosters good relationships with your patients. Patients appreciate your extra efforts in advising them that you are submitting this information to their insurance carrier for them to feel more comfortable about what you are estimating their out-of-pocket total to be.
While these steps are taken to help the office collect the correct amount the day treatment is rendered, there are many other benefits to taking these steps. Once the treatment is rendered, the processing of the actual claim goes much faster if an insurance carrier has already rendered a positive judgment that they agree with the proposed treatment course by the dentist.
About the Author
Laura Tucker, MAADOM
I am in my 32nd year as the office manager for Floyd Simon, Jr., DDS in Clinton, Oklahoma. Current board member of our DPLN group in OKC, Oklahoma. Current Practice Administrator for Brett R. Warn, DDS in Lawton, Oklahoma.
Laura is a trainer in various dental offices for clinical/front office staff members.
Laura has 3 beautiful children – Mitchell, Micah, and Manning- and is a current MAADOM distinction holder.
