Answers about insurance

Working with dental insurance continues to be a common source of difficulties for most offices. Financial matters in general cause misunderstandings. Dental-insurance issues compound the problem.

Carol Tekavec, RDH

Working with dental insurance continues to be a common source of difficulties for most offices. Financial matters in general cause misunderstandings. Dental-insurance issues compound the problem.

Our attitudes concerning patients` dental insurance can be helpful or harmful. When we view insurance as a vehicle aiding patients in paying for necessary treatment, we help patients. When we view insurance as the determining factor in what treatment a patient will accept, we harm patients.

Question: Insurance companies change the codes on my patients` claim forms to codes our office has never heard of. Aren`t we all supposed to be using ADA codes?

Answer: Insurance carriers base their coding systems on the ADA Current Dental Termin-ology-CDT-2. However, nothing prevents them from inventing their own codes to describe procedures. A claim for a procedure not covered under one code in a patient`s contract may be covered under a carrier`s individual code.

For example, a claim for ADA Code 04355-Full Mouth Debride-ment may be changed to an individual carrier code, such as Delta of Michigan`s 01130 Difficult Prophylaxis (reference November 1997 definition) and paid at the rate allowed by the patient`s contract.

Patients who have insurance contracts containing a LEAT clause (Least Expensive Alterna-tive Treatment) may find certain procedure codes and payments changed to less expensive codes and payments. As an example, a three-surface inlay, Code 02630, might be changed to a Code 02160-three surface amalgam and paid at what the contract allows for the amalgam.

Question: Does this mean that only an amalgam can be performed?

Answer: Absolutely not! Insur-ance contracts dictate what may be paid, not what can be performed.

Question: Several of our patients have insurance with XYZ company. Even though these patients are all with the same insurance company, their benefits are not the same. Why is that?

Answer: The same insurance carrier may provide coverage to numerous employers. Each employer may choose a different contract. It is even possible for employees of the same employer to have different benefit plans. That is why it often is helpful to send for a predetermination of benefits prior to beginning treatment - so a patient will know just what his or her insurance will cover.

Contrary to popular belief, waiting for a predetermination does not necessarily cause a patient to get "cold feet" about proceeding with care. If a patient decides against treatment based on what insurance will pay, it is better to know that finances are a problem before the patient begins treatment. A patient who does not want to pay for his or her treatment, but already has had procedures completed, can become a very difficult collection problem.

(While a predetermination does not compel insurance to pay, it does provide a guide to benefits. As always, a detailed treatment estimate with the patient`s responsibilities clearly defined and presented prior to any treatment is the best way to approach finances and insurance.)

Question: Another dental office tells us that we must accept what a certain carrier pays us as total payment. Isn`t the patient always responsible for what insurance doesn`t pay?

Answer: The answer is both yes and no. If a dentist has an individual contract with a carrier that stipulates he or she will accept the insurance payment as total payment, it usually is not possible to bill the patient for the difference between the dentist`s normal fee and what the insurance pays. In the absence of such a contract, any unpaid balance should be charged to the patient.

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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