Understanding Dental Insurance Pre-estimates vs Pre-authorizations
Understanding dental insurance pre-estimates is tricky. So, let’s begin with a definition. A pre-estimate is a document and a process. The dental office sends a pre-estimate to dental insurance. It’s sent as a claim form marked “pre-estimate.” We do this to receive a cost estimate for our patient. And we wait for the insurance carrier to process. The patient receives a copy. And the dental office does too.
Some insurance policies require pre-authorization. And often for major procedures. But sometimes for periodontal treatment too. And this is a different thing! It’s a great question to ask during an insurance verification. “Are pre-authorizations required for dental services?” This is a great question to ask!
Pre-estimates and pre-authorizations are different. Pre-estimates give us patient benefits. Pre-authorizations allow patients to receive dental treatment and use benefits. And often come with expiration dates. A pre-estimate expires as well. So we want to watch this!
Flag Pre-Authorization Accounts
Flag accounts for required pre-authorizations. Create an attention getter! Something no one can miss. And be sure not to skip this step. Or a patient might just miss out on their benefits. It doesn’t happen often. But it does happen. And creates a case for careful consideration.
Some offices send pre-estimates for everything! And I understand why. The pre-estimate numbers are the foundation for financial conversations. However, we must watch these numbers carefully. Pre-estimates are often not accurate. And we may need to do our own math!
Understanding Dental Insurance Pre-estimates Limitations
Dental insurance pre-estimates may not include some important benefit information. For example, frequency limitations. The dental office may send a pre-estimate for a full upper denture. The insurance pre-estimate returns to the office with an answer. The patient has 50% coverage and their estimated cost is $500. But there is something you don’t know. The patient has a frequency limitation for dentures of 7 years. And their current denture is 6 years old.
It’s different for every insurance company. Some insurance companies do not factor in deductibles and yearly maximums. So there really is a lot to this. And although it’s tempting to just use their numbers, it’s not good practice. Because we then end up with high receivables and unhappy patients.
Re-calculate Upon Receipt
You’ll be so glad you did! Know the patient’s benefits. Verify patient benefits as they enter the practice. Track benefits used. And be sure to understand as much as you can. Then re-calculate based on what you know. A few steps now saves many more later. And fosters better patient relations too.
There is no guarantee of payment. This is one thing dental insurance repeatedly tell us. We can count on nothing! Anything a dental insurance plan pays is a bonus. I like to share this with patients. And let them know I am here to help. I want them to receive all the benefit they can. And I avoid the words “insurance coverage”.
Understanding Dental Insurance Pre-estimates: The Send Off
Send your dental claim as normal. Include the usual x-rays and supporting documentation. A copy of the pre-estimate is not necessary. However, a pre-estimate often extends an offer. You may fill in the date of service and signatures and return by mail. But, snail mail is just that.. snail mail. If that’s the only option, then so it is. However, to send an electronic claim with no pre-estimate attached is just fine.
Pre-authorizations must be attached to an insurance claim. Fill in the date of service and any other blank lines on the form. Attach it to an insurance claim. Be sure to include any supporting documentation. And send off in the mail. I avoid sending pre-authorized services electronically. It’s just too easy to “lose” the authorization form electronically. A staple or two might just save the day. Be sure to keep a copy for yourself!
Pre-estimate Aging Reports
Run a pre-estimate aging report at the beginning of each month. Or you might prefer to run this at the end of each month. Follow-up on any pre-estimate that is over 30-days. And keep this clean. We want to enter our pre-estimates into our software system as we receive them. This clears our pre-estimate aging. Which can clog up our software and slow it down.
Keep an eye on pre-estimates attached to scheduled appointments. And this is an absolute for pre-authorizations. I like to make notes on a patient appointment itself that a pre-estimate was sent. However, it has not been my practice to pre-estimate all treatment. Only for unusual situations or at a patient’s request.
Use Them To Your Advantage
Take advantage of what the pre-estimates offer. This is an opportunity to help educate patients about their benefits. And the challenge in calculating their copay with accuracy. I always call patients with the pre-estimate information. And explain why I see their insurance may pay something different. Especially with yearly maximums. PPO providers are able to charge UCR once a patient’s maximum is reached. And this may not be reflected in the pre-estimate.