Insurance issues are one of the primary reasons for dental claim denials, which can lead to significant financial disruptions for practices. It’s essential for dentists to understand patients’ insurance plans to help patients get accurate information about their coverage, plan for their treatments, and avoid unexpected expenses. As navigating the details of patients’ dental coverage and benefits can be a complex and frustrating challenge, many dental offices rely on professional dental insurance verification services. Experts can help providers verify patients’ coverage before treatment, helping to prevent claim denials due to eligibility issues while facilitating timely and accurate reimbursement.
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Ideally, insurance verification should be done before the treatment begins, particularly for costly procedures, to avoid surprises for the patient. As we step into 2025, make sure your practice proactively verifies patient eligibility by implementing these best practices.
Strategies for Streamlining Dental Insurance Verification
Collection of Patient Information
The collection of patient information is typically done at the initial point of contact with the dental practice. Details to collect include
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- Personal information: Full name, date of birth, address, and contact information.
- Insurance details: Insurance company name, policy number, group number, and the insured party’s details (whether it’s the patient or a family member).
- Effective Date: Verifying the start date of the insurance policy to confirm coverage is active.
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The collection of patient information can be done during several stages of the patient’s interaction with the practice, depending on the specific procedure. It is done during the initial registration process for new patients or before each appointment for existing patients, especially if there are updates to their insurance or medical details.
Eligibility Verification
This critical step confirms the patient is eligible for dental services under the policy.
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- Check covered benefits: Check which dental services are covered (preventive, restorative, orthodontic, etc.) and the specific benefits for the patient (e.g., frequency of cleanings, coverage for fillings, etc.).
- Co-pays and Deductibles: Understand any out-of-pocket costs the patient will be responsible for, such as co-pays, deductibles, and annual maximums.
Verify Insurance Coverage on the Date of Service
Before providing treatment, dentists should verify a patient’s insurance coverage. This can be done by logging into the patient’s insurance portal or by calling the toll-free number on the patient’s identification card. However, the American Dental Association (ADA) reminds that, in some cases, the patient’s dental plan may not have been promptly notified by the employer about the termination of the patient’s employment and/or associated benefits. As a result, the information verified through the payer’s portals or call centers may not be current or accurate. This makes it essential for dental offices to verify eligibility on the date of service by asking patients questions during the visit to check for potential eligibility changes since their last visit, including:
- if their insurance has changed
- if they or their policyholder had any recent employment changes
- how long the dental plan coverage will remain in effect after the employment change, or how the change might affect their coverage
Patients should be asked if their employer provided them with paperwork about their insurance changes.
Understand the Clauses in Dental Insurance Plans
Dentists should understand the clauses in dental insurance plans to help patients get the most out of their coverage and prevent issues that could affect revenue. Top things that dental offices need verify include:
- In-network or out-of-network: Most PPO plans provide benefits for out-of-network dentists, whereas exclusive provider organization (EPO) plans only cover services from network dentists. If a patient chooses to see an out-of-network dentist, no benefits will be paid.
- Explanation of benefits (EOB) statement: The EOB should clearly spell out benefits, limitations, and exclusions as well as how deductibles, co-payments, and coinsurance factors apply.
- Referral or Pre-Authorization: Some insurance plans may require pre-authorization for certain services, especially if the patient is seeing a specialist or if the procedure is expensive.
- Least expensive alternative treatment (LEAT) clause: The LEAT clause means insurance will only cover the least expensive treatment for a dental issue. If a patient chooses a pricier option, they must pay the difference. Dentists can provide a pre-estimate to clarify these costs.
- Missing tooth clause: This clause means if a patient lost a tooth prior to getting the insurance, any treatment for that tooth may not be covered.
- Non-covered services: Non-covered services in dental plans are treatments that insurance does not pay for, such as cosmetic procedures or certain orthodontics. Patients must cover the full cost of these services, so reviewing the plan details is essential to understand exclusions.
Understand the Patient’s Benefits
Dentists should understand the patient’s benefits, including their coverage percentage, maximum allowance, and benefit year.
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- Coordinate benefits: If the patient has more than one dental insurance plan, it should be determined which plan is primary and how much each plan will pay.
- Maximums: Many dental plans have a yearly maximum limit on how much they will pay for dental services. It’s important to verify the remaining balance for the year. Some plans have a lifetime maximum for certain services, such as orthodontic treatments, which must be checked in advance.
- Frequency limits: Understand any restrictions, such as how often a patient can receive certain services (e.g., cleanings, X-rays, fluoride treatments).
- Deductible: This is the amount a patient pays before the insurance company starts paying.
- Exclusions: Identify procedures or services that are not covered by the insurance plan (e.g., cosmetic procedures, certain types of orthodontics).
- Treatment codes: Verify the proper procedure codes (CPT or CDT codes) to ensure that the planned treatment is eligible for reimbursement.
Patient Communication
Patients should be clearly informed about their coverage, including details on co-pays, deductibles, out-of-pocket costs, and which procedures are covered under their plan. If a procedure is not covered, it’s important to clarify whether the patient will be responsible for the charges, based on the terms of their insurance contract. Additionally, patients should be reminded that their out-of-pocket estimate is only an estimate. Ultimately, patients are responsible for the full cost of their dental treatment, regardless of the estimate provided.
Claim Submission
Claims are submitted to the insurer after treatment. Some dental procedures are covered under a patient’s medical policy, and often, the medical policy must be billed first. Comprehensive verification ensures accurate information for prompt and successful reimbursement.
Maintain Documentation
Maintaining accurate records of the insurance verification process is essential for dental practices to ensure proper documentation, facilitate efficient claims submission, and avoid issues with billing and reimbursement. Information to record includes:
- Eligibility verification details and date
- Changes to insurance providers or policies
- Updates to coverage limits or benefits
- Authorization details
- Any issues with the patient’s eligibility status or gaps in coverage
- Communication with the insurer
- Written communication with the patient on their insurance coverage or treatment estimates
- Patient consent and acknowledgement
Maintaining accurate records of the insurance verification process supports smooth claims processing, accurate billing, and compliance with insurance requirements.
Reasons to Outsource Dental Insurance Verification
Performing patient eligibility verification during scheduling and just before the visit is essential for efficient dental revenue cycle management. Partnering with a dental eligibility verification specialist can ease this challenging task. Outsourcing save time and improve your practice in many ways:
- Hassle-free verifications: Missing even a single detail can be costly for both the physician and the patient, who may be left with an unexpected bill. Outsourcing insurance verification ensures the process is handled efficiently. An insurance verification specialist will confirm the patient’s eligibility for treatment at the time of scheduling, preventing errors and surprises.
- Faster payments: Early verification of insurance details, ensuring that claims are submitted accurately and processed quickly, reducing delays in payment.
- Improved financial health: By confirming eligibility, practices can prevent underpayments or missed reimbursements, improving overall financial stability.
- Prevents common claim denial issues: When experts handle the process, it prevents errors that can lead to claim denials by:
- Ensuring patient details are accurate to avoid rejected claims.
- Detecting if a patient’s insurance coverage has expired or changed before treatment.
- Preventing billing for procedures not covered by the insurance plan.
- Compliance with regulations: Timely and accurate dental insurance eligibility verification helps ensure the practice complies with healthcare regulations (e.g., HIPAA), reducing the risk of legal or financial penalties.
- Improved patient relationships: Outsourcing frees up time to focus on patients and improves care delivery, building loyalty and retention. Additionally, it ensures patients are informed about their coverage and out-of-pocket costs upfront, which reduces surprises and improves their experience.
Outsourcing dental insurance verification to experts ensures that the process is handled with precision and efficiency, adhering to industry best practices. It minimizes errors, reduces administrative burden, and improves the accuracy of coverage information, leading to smoother claim submissions and faster payments.
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