Read the Fine Print
Dental offices focus on policy benefits and exclusions when verifying coverage for their dental patients, because that is the standard operation for determining estimated insurance coverage and out-of-pocket responsibilities of patients. What often is the bane of getting paid is the Processing Policy Provision, or as some say “the fine print” in the policy plan.
A little known fact is that every PPO has a Processing Policy Manual. The dentist who signs the contract agrees to abide by and comply with all of the provisions in the manual. Most dentists don’t have the time or take the time to actually read “the fine print” until they are forced to write off a procedure that was denied.
Dentists and their managers often look at the intended fee schedule for each plan when determining whether it is feasible for the practice. It is usually determined that volume in patient numbers will be necessary to offset the lower than profitable dollars paid. Management of internal costs including payroll are the key to being profitable in a PPO or HMO dental market.
The group or individual dental plan contract (plan document) and the processing policy manual are two separate documents, and the plan document will overrule the processing policy. To be proactive in preventing unnecessary write-offs, be aware of the following by reading the “fine print” in the Processing Policy or Plan Document.
Some clauses that may be found in Processing Policy Manuals (can be found on the insurance company’s website or you should have one issued at the time of signing contract):
1. You may have taken x-rays of a patient who made it difficult to get a great exposure because of movement, gagging or complaining. But if it is not of diagnostic quality determined by the insurance company consultant, you won’t be paid – or if you were paid, you will now have to refund the insurance company. X-rays can also be denied if “medical necessity” documentation isn’t provided.
2. When the insurance company asks for a refund within a certain time period and you don’t comply, they can subtract that amount from a patient’s benefits in the same group or from the same family.
3. There are policy provisions in some plans that state you cannot perform four quadrants of root planing in the same appointment. They can deny the entire visit and you cannot bill the patient.
4. If the claim was paid and it was later found that the patient was ineligible, the practice has to refund the money but can bill the patient since they weren’t covered at the time of service.
5. Some policies require a pre-determination and if you treat the patient without one there will be zero benefits.
6. Payments from the insurance company can be issued in any form they see fit without your approval, such as virtual credit card payments, and some require EFT to your bank account. Some will work with you on this and some won’t.
7. Each plan determines its “incurred liability date” and that could be the date of preparation or the date of seat. If the plan pays on the seat date, the procedure must be billed on or after that date.
8. Each policy has a claim filing statute of limitation. Some are 90 days and some up to a year. A claim filed after the date will not be paid unless there were circumstances that affected the office operations such as a tornado, flood or earthquake.
9. Some policies have restrictions and will not pay and also will not allow you to bill the patient. Among those are pulp caps on the same date as the filling, core build-ups on the same day as the crown prep, x-rays without evaluations, one restoration on each tooth per 24 month interval, every 24 months periodontal assessment or a decline for a D4910 – and the list can vary from one plan to another.
10. Some plans (varied from state to state) will not allow you to bill the patient for a non-covered service or will direct you in what you can charge for the service if it is not a covered benefit.
11. Benefits may say implants are covered but if there is a “missing tooth clause” on the contract and the tooth was extracted prior to coverage, there will be no benefit at all.
It is prudent to be knowledgeable in the in-network dental plan arena to save you headaches in patient care, customer service and administrative costs. McKenzie Management offers Front Desk Training and Office Manager Training customized to your needs, with dental insurance processing as an important part of the training.Forward this article to a friend
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