Records, Risk and Reimbursement

Coordination of benefits is one of the aspects of dealing with patients` dental insurance that makes many offices wonder if the hassle and paperwork involved is worth directly receiving the insurance-benefit check. A dentist can eliminate the problem by simply requiring patients to handle their own insurance submission. However, if your office has made the decision to help patients utilize their benefit plans, you will find yourself faced with the frustrating problems surrounding this issue.

Carol Tekavec, RDH

Coordination of benefits is one of the aspects of dealing with patients` dental insurance that makes many offices wonder if the hassle and paperwork involved is worth directly receiving the insurance-benefit check. A dentist can eliminate the problem by simply requiring patients to handle their own insurance submission. However, if your office has made the decision to help patients utilize their benefit plans, you will find yourself faced with the frustrating problems surrounding this issue.

Patients who are fortunate enough to be covered under two dental-benefit plans often believe that their treatment will be covered at more than 100 percent, or even at twice the actual fee. While some procedures performed on dual-coverage patients may be covered to the extent that the patient is not required to pay any portion of the bill, insurance plans that provide for "Coordination of Benefits" are designed so that the secondary insurers do not pay more than 100 percent of the covered charges. In fact, the primary reason insurance plans provide for coordination of benefits is to prevent subscribers from making money on claims.

Primary coverage

To determine a patient`s benefit, the primary and secondary insurance must be identified. A plan without a COB provision always is primary. If both plans have a COB provision, then the plan that is covering the patient directly (the patient is the employee) is primary. If two plans cover the patient directly, then the plan that has been in effect the longest is primary. The primary insurer must pay first, and then any remaining expense may be submitted to the secondary plan. The secondary plan may pay up to 100 percent of allowable expenses. If the primary plan knows that the patient`s other plan will pay a certain percentage as a secondary plan, then it may reduce its normal payment. Many insurance plans have other stipulations that limit their liability. Two of these (and individual plans may have others not listed here) are "maintenance of benefits" and "non-duplication of benefits." "Maintenance of benefits" clauses limit the secondary insurer to only what the primary insurer will accept. "Nonduplication of benefits" clauses simply state that a plan will not pay if it is secondary.

Determination of coverage for children can be even more problematic. The "Birthday Rule" is accepted by most insurance carriers providing coordination of benefits. This rule stipulates that the primary plan for a dependent child of two parents who are married to one another will be the plan of the parent whose birthday comes first in the year (unless the parent whose birthday falls later in the year has a plan that does not have a coordination of benefits provision, in which case it would be primary). Children whose parents are divorced present more confusion. Frequently, the court will stipulate which parent must pay for a child`s health expenses. If the court has assigned this responsibility, then the assigned parent`s insurance plan will be primary. If there is no court assignment, then the parent having custody of the child will have the primary plan. If the parents have remarried, plan primacy will be in this order: First, the court-assigned responsible parent`s plan; second, the plan of the parent with custody; third, the plan of the spouse of the custodial parent. Experience has shown that in cases of divorce, separation, and remarriage, the financial coordinator for the office should obtain a "responsible party" signature of the parent bringing the child in for treatment.

Medical insurance

When a patient has medical insurance that may cover a portion of dental treatment, there are various opinions as to how to approach claim submission. The American Academy of Periodontology recommends that claims to medical plans only be considered when the patient has a condition caused or complicated by a medical problem or accident. Indicate the existence of dental coverage on the medical claim form and vice versa, and submit the same, total fee for treatment to both plans. Submit to the medical plan first, then attach the EOB (Estimate of Benefits) statement to the subsequent dental claim. The medical claim must be submitted on a standard HCFA 1500 form, using ICD and CPT codes. This controversial area of benefit payment is in a constant state of change. What applies today may not apply tomorrow.

COB with managed-care plans

Coordination of benefits between standard-insurance and managed-care (managed payment) plans are subject to state regulations. Currently, there are few, definitive guidelines to follow. Coordination of benefits is generally applicable if the insured person receives treatment from a participating provider under a managed-payment plan. Standard- insurance plans usually will consider only the true out-of-pocket expense the patient has experienced under the managed-payment plan, not the usual fee of the dentist. If a treatment is not a covered benefit of the managed-payment plan, coverage might be available under the standard plan. If the managed-payment plan is secondary, the office should submit to the standard-insurance plan first. If the primary plan pays more than the contractual payment required by the managed-payment plan, the dentist may waive that payment.

Carol Tekavec, RDH, is the author of two insurance-coding manuals, co-designer of a dental chart, and a national lecturer. Contact her at (800) 548-2164 or at www.steppingstonetosuccess.com.

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