Calculating Dental Insurance Payments
Understanding Dental Insurance
Calculating dental insurance payments can seem complicated. However, it only seems that way if you don’t really understand it. Now, don’t be mistaken here, as there really is quite a bit to it! And it’s extremely important that you do fully understand it, if you are the person responsible for dental insurance estimates in your practice.
Dental insurance is important to dental patients. Some patients understand their benefits better than others. Many patients don’t even know the name of their insurance company. Often times, patients leave their dental insurance in the hands of their dental providers. And they count on their providers to maximize their coverage! (They also expect us to know everything about it! Including their ID #’s!!)
This is where we can shine! Sure, you could say that the responsibility is really the patients’. That doesn’t accomplish much. Except to put up a barrier between the patient and the dental office. Taking the time to understand dental insurance will improve your patient relationships. As you educate your patients about the dental insurance process and their coverage, you will be their hero!
Educate Your Patients
Education occurs through treatment completion. As you are working through specific dental procedures with patients, education begins. Explain everything about their insurance plan to them. Inform your dental patient that they have a yearly maximum and what that is. Show them what their deductible is. Help to to see what their coverage amounts are for procedures.
Include your providers’ usual and customary rates. You definitely want your patients to see what your providers charge in full for every dental procedure. It helps them to see what their cost would be without dental insurance. It is also beneficial for your patients to see any contractual adjustments or write-offs.
Encourage dental patients not to be bound by their dental insurance. Help them to be comfortable moving outside of their insurance company’s limitations. With positive reinforcement, dental patients can feel empowered to rise above what their insurance company is offering.
Calculating Dental Insurance Payments
Getting The Full Break Down
Calculating dental insurance benefits starts with a great breakdown of benefits. Most insurance companies have web-sites where you can access patient benefits. There are also companies available to help us with our table of benefits and patient history. Gathering individual patient benefits and history is a time consuming task! And we do well to take advantage of all the help we can get!
Sometimes, we will need to call an insurance carrier. But either way, it’s important for the dental front office team to have a good handle on what they need to know. What benefit information will we really need to look for? Whether we search an on-line portal through an insurance carrier’s website, use a third-party vendor, or call ourselves, we need to know what to ask!
If you need an insurance verification form, you can download one right here! There may be additional information that your dental office needs if you specialize. Perhaps you work in pediatrics, and need information not listed. You can edit or change this any way you need to. It won’t hurt my feelings one little bit!
Go ahead and take a look at that form. Let’s work through it together. I’ll explain what is what and why it matters. We’ll be calculating dental insurance benefits with examples along the way. Ready? Let’s get started. Calculating dental insurance payments starts with information gathering.
Gathering information is critical. One wrong piece of information means you can’t get the insurance coverage. Be sure to get the patient’s full name and date of birth. Ask if they are the subscriber or if someone else is the subscriber. If someone else, like a spouse is the subscriber, you will also need their date of birth. You will also want know if this is a self-purchased individual plan, or if the plan is through an employer.
It’s most important to get the insurance company’s phone number and member identification number. Many dental patients don’t even know the name of their insurance company. Really! With the member identification number, and the patient’s name and date of birth (and the subscriber’s name and date of birth), you can get things like the claims address and group number. But try to get whatever you can from the patient themselves.
The effective date of the policy is very important. Especially if there are waiting periods or limitations on the policy. It is also important if a secondary insurance company comes into play. This information will prove invaluable to you. You will be scanning this verification form to the patient’s chart and will have the effective date on file to revisit later when needed.
Calendar Year or Fiscal Year
Knowing this helps you to know when a patient has neared their yearly maximum. A calendar year runs from January through December. A fiscal year runs from July through June of the following year. Having this right means a lot. Especially as you approach the end of the patient’s benefit year. Overestimating a patient’s insurance coverage will leave the patient with a much bigger out of pocket expense. It would come as an unpleasant surprise to you both.
Annual maximums. Patients sometimes don’t know that they have a yearly maximum. I’ve been surprised at the number of patients who think they have an unlimited amount of money available to them. They are often surprised that it is reached so quickly in the year. Most annual maximums are between $1000.00 and $1500.00. Although they can vary from $500 upwards. The important thing to remember is to subtract any benefits paid by the insurance company from the annual maximum as benefits are paid out. Most dental software will do this for you. However, benefits can be paid to other providers too. This is where it gets tricky! Stay on top of it and you’ll be okay.
Separate maximums for preventive care. You can also find some policies with a separate maximum for preventive care. This is great for patients, as it means their cleanings, exams, and x-rays do not apply against their restorative maximum. Patients get really excited about this! And rightly so.
Annual deductibles. Most dental insurance plans have an annual deductible of $25.00 to $50.00. They also usually have family deductibles of $75.00. But again, they vary from policy to policy. Sometimes, deductibles include preventive services (cleanings, exams, x-rays) and sometimes it is only for restorative care (fillings, root canals, crowns, etc.). Occasionally, it is some strange combination of both. Note what procedures your patient’s deductible applies to. Again, most software will help you track this, You may have to let it know when an insurance payment has included payment towards the deductible.
Calculating Dental Insurance Payments
The Actual Break Down
You are going to want the exact coverage amounts for all of these specific procedures.
Preventive: Usually covered at 100%, but can be at 90%, 80%, or even 50%. (prophy, exam, x-rays)
Basic: Usually covered at 80 %, but can be more or less. (fillings)
Major: Usually at 50%; but can be more or less (crowns, bridges, dentures)
Perio: Usually at 80% but can be more or less (periodontal procedures)
Endo: Usually at 80% but can be more or less (root canals)
Oral Surgery: Usually at 80% but can be more or less (extractions)
Post & Core: Vary policy to policy (sometimes placed with a crown)
FMD (D4355): Vary policy to policy (Full Mouth Debridement)
Buildup: Vary policy to policy (sometimes placed with a crown)
Implants: Vary policy to policy
Night guards: Vary policy to policy
Frequency Limitations and Waiting Periods
***Waiting periods sometimes exist on a policy. A member must wait a certain period of time before having specific procedures completed. This is especially true on individually purchased dental insurance plans. For example, a patient may have to be on their insurance policy for 6 months before having any coverage for fillings. They might also need to be on their insurance policy for 12 months before having any crown coverage. This is important to know.
***Frequency limitations tell us how many times a patient will have coverage for a procedure. For example, a patient may have coverage for an adult prophy 2 times in a calendar year. Or, they could also have an adult prophy covered once every 6 months. Big difference for the dental practice in scheduling. Be careful!
This can be a source of frustration. But only if you let it. It’s important when providing dental insurance estimates to your patients to know this. Some insurance plans pay for the least expensive procedure. Especially for molars, insurance plans do not want to cover the resin material for a composite restoration. They prefer to pay the amalgam. The patient is responsible for the rest.
Let’s do the math. $250 Dentist UCR Composite Restoration
$150 Fee For Amalgam (because it is downgraded we will use the amalgam fee)
$150 Is The Amount To Use To Determine Estimate
– subrtract $50 Annual Deductible
$100 Is The Amount To Continue Calculating
80% Insurance Pays= $80
20% Patient Pays = $20 +$50(ded) + ($100 difference) = $170.
Insurance companies will sometimes downgrade posterior crowns. This could make a big difference in your patients copay amount. Calculating this downgrade into patient co-pays will save you and your patients from unwanted frustration. Not all insurance companies downgrade posterior crowns. Be sure to check!
Here’s How It Looks: $1085 Dentist UCR (Porcelain Crown)
$850 Less Expensive Crown
$235 Difference in Crown Types
$850 The Amount Used To Determine Estimate
$800 Is The Amount To Continue Calculating
50% Insurance Coverage = $400
50% Patient Pays = $400 +$50 (ded) + $235 Difference = $685.00.
What’s A Missing Tooth Clause?
A missing tooth clause on a dental insurance plan will not cover a restoration for a tooth that was missing prior to the effective date of a policy. There are some exceptions to this. Some plans will cover a restoration like this if the patient has been covered by the plan for a certain number of years. It could also be over ruled if a patient has worked for the same employer and had dental insurance for some time with that employer. Ask questions about this if it comes up for your patient.
Additional Support In Calculating Dental Insurance Payments!
Get the help you deserve! I have worked with many dental administrative professionals who needed a little support with their math skills and the understanding of dental benefits. Calculating percentages and deductibles is not something we all know. A little one -on- one with your dental administrative team could mean all the difference for your receivables and patient relationships! Please reach out to me today and let’s chat!