Dental Administration 101INSTRUCTOR

Robbie Heath | 919 271 8863

What is Dental Insurance

a. Coverage for individuals that provides assistance with paying for the cost of dental treatment

b. Medical designed to cover costs associated with diagnosing and treating medical illness

c. Dental designed to provide coverage for preventative dental services-Patients assume larger portion

Group Dental PlansDental benefits sponsored by an employer

1. Insured- Employer pays a portion of monthly premiums to an insurance company on behalf of the employee. Insurance company pays providers

2. Self-funded- Employer collects premiums and invests the funds. Dental claims are processed and paid by the employer to the provider

Preferred Provider Organization- PPOPatients have a choice in choosing providers but benefit most by

using an “in-network provider”

In NetworkInsurance carriers and dental providers agree upon a contract that sets pre-negotiated contracted rates for reimbursement by providers. Rates are determined by the insurance carrier and are based on UCR (usual, customary, and reasonable fees)

Out of NetworkRefers to a patient covered by a PPO plan who chooses to receive care from a dental provider that does not have an agreed upon contract with the insurance carrier

Managed Care Plans- DMHO, HMO

Insured patients must see participating assigned providers only

Less expensive to employers

If patients go outside of network they are financially responsible for all charges

Managed care plans do not pay non-participating providers

Providers may only refer to specialist also participating in the managed care program

Direct Reimbursement Plans

Self-funded plans

Reimbursement to the plan member by the employer/plan

Plan member pays total bill to the provider at the time of service

No insurance carrier involvement

Carrier- The insurance company (ex. Metlife, Cigna, Guradian) Group- Employer or organization that provides the dental plan to the

employee Group number- Unique number assigned by an insurance carrier to

identify the employer or group sponsoring the insurance coverage for an employee

Subscriber- The employee or member who holds the insurance plan Dependent- Family member or spouse of a subscriber who is eligible

for benefits sponsored by the subscriber Provider- Dentist or dental office that provides dental treatment

Who is Involved?

Individual Plans Work as group plans except there is no employer. Patient purchases and pays premium for their own insurance coverage Copays and deductibles still apply

Tax Funded Plans Medicare- Provides medical coverage as part of social security benefits; does

not provide dental coverage Medicaid- State and federal funded medical and dental insurance coverage.

Fees are paid directly to the provider through state or federal funded plansa. Pays approximately 50% of the bill to providersb. Participating providers must write off the remainder bill for patients under

the age of 18c. Adult patients are only billed $3.00 per visitd. Strict rules regarding allowable procedures

Discount Plans Not an insurance plan Provided through insurance carriers Participants pay a small yearly fee to be allowed to receive the discounted

contracted fee from participating providers No insurance claim to file Participants directly pay discounted fees to provider at the time of service

Uninsured Patients Subject to full price of dental procedures Does not benefit from contracted rates May need or benefit from payment plan Care Credit vs In-house financing

Understanding Patient’s Benefits Breakdown of Benefits refers to the outline and criteria of benefits a

plan offers

Breakdown of Benefits form is specific to the needs of an office and is used to notate plan benefits

This form covers certain needed information

• Subscriber Information• Patient Information• Insurance Company Information

What is an Effective date & Why is it Important?

• Eligibility-Is the patient eligible for services on the date of service

• Waiting periods-An amount of time a patient must wait before eligible for services

a. Preventative Services usually are not subject to a wait period

b. Basic restorative services are usually subject to a 6 month wait

c. Major services may include oral surgery, prosthodontics, periodontics, and endodontics and usually are subject to a one year wait

Prior placement or service dates

Replacement Period- The amount of specified time a patient must wait before the insurance will pay towards replacing certain procedures such as dentures, partials, bridges, and crowns. Usually 5-10 years

Missing Tooth Clause- Protects insurance carriers from tooth replacement costs for teeth missing prior to the plans effective date

Benefit time period• Calendar year- January 1 to December 31• Benefit year- Start date of plan running for one year

Deductibles

A set dollar amount a patient will have to personally satisfy prior to the insurance carrier contributing to the dental bill

• Usually $25.00, $50.00, or $100.00• Usually applies to services other than preventative and diagnostic

Yearly Maximum An annual dollar amount an insurance plan will pay toward the cost of dental care within a specific benefit period

• Usually 1,000, 12,00, or 1,500 per year• All payments for any reason paid by insurance is subtracted from

this amount

Coinsurance A percentage or portion of the cost per procedure that is paid by the plan member

• Outside of the deductible• Usually in a percentage amount

Three Levels of Coinsurance

Preventative & DiagnosticExams, Prophies, X-rays, Sealants, Flouride

Basic RestorativeFillingsPerio, Endo, and Oral Surgery Vary by Plan

Major ServicesCrowns, Dentures, Partials, Implants, Bridges

Services Particular to the Individual Provider or Group

• Sealants & Flouride treatment coverage and age limitations

• Debridements• Buildups• Implants• Nightguards• Nitrous Oxide (N2O)

Other Important Benefit Information

Frequency LimitationsDescribes how often a particular service is covered by a dental insurance plan.

Exams Prophy FMX/Panorex Bitewings Perio Mainanence Scaling and Root Planing Fillings 6 months vs 2 per calendar year

History

Due to frequency limitations, providers must know the dates of most recent services

Date of last FMX/Pan Date of last prophy Date of last Exam Date of last bitewings

Billing of Dental Crowns

Prep Date- insurance carrier requires that the crown be billed on the day that the tooth is prepped

Seat Date- insurance carrier requires that the crown be billed on the date the crown is permanently delivered. Date of prep and seat must be notated when billing

Common area for insurance fraud

When billed on seat date- core buildup is billed on prep date

How Are Insurance Carriers Billed

Dental providers communicate with insurance carriers through dental claim forms

ADA Dental Claim Form Mail Electronic Insurance carriers have 30 calendar days to respond to

dental claims Non-compliant insurance carriers can be reported to

the NC Insurance Commissioner

Assignment of benefits

Patient is assigning his or her insurance benefits to the dental office as payment of the treatment received

Payment goes directly to the provider Assignment of benefits must be authorized on the dental claim form

PredeterminationsItemized list of dental services that a patient requires, rather than has been completed, and is submitted by dental claim form

Not a request for authorization to begin treatment A written document stating exact amount of reimbursement an

insurance carrier will pay towards needed treatment Not a requirement

Secondary Insurance Patient is covered by his/her own sponsored employer insurance Patient, in addition, is covered by spouses employer sponsored

insurance plan as a dependent

Coordination of Benefits applies• Responsibility of dental office administrator• Patients employer sponsored insurance plan is always the

primary• Birthday rule- applies to dependents of parents who both have

employer sponsored insurance plans: the insurance plan of the parent whose birthday occurs first in a calendar year is the primary plan for all dependents