Calculating Dental Insurance Payments - Understand 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.
Insurance is Important to Patients
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!!)
We Can Shine!
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
Patient education builds trust. As you are working through specific dental procedures with patients, education expands. As does trust. 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 them to see what their coverage amounts are for procedures.
Calculating Dental Insurance Benefits Builds Patient Trust
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.
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Calculating Dental Insurance Benefits Begins with a Breakdown of Benefits
Calculating dental insurance benefits starts with a great breakdown of benefits. Most insurance companies have websites 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!
Effective Date
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 both parties.
Other Considerations and Terminology
Deductibles
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.
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!
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 overruled 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.
Downgraded Fillings
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.
Downgraded Crowns
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!
