Alternate Benefit Clause in Dental Insurance

Today I will be discussing the Alternate Benefit Clause in Dental Insurance.

I am sure you are already aware of the alternative benefit clause. Most insurance carriers implement it in at least one covered category.

It is a cost containment feature in an insurance plan which states that if there are two or more professionally acceptable dental treatments that will work for a dental condition, the plan will pay for the least costly treatment alternative. It is also referred to as a “downgrade”, and it can mean higher out-of-pocket costs for the patient leaving them paying the difference between the two of these.

Downgrades can apply to several different procedures. Here are a few examples:

• Fillings: Fillings can be done using an amalgam material which is the silver or a resin composite and that is the white filling material. Amalgam fills tend to last about ten to fifteen years. They are more affordable. And then the resin composite fillings – they mimic the natural appearance of teeth, and they are a little costlier and they usually about last five to seven years. Often, insurance plans pay for the cheaper silver filling, especially when it comes to posterior teeth.
• Posterior crown: Materials used to make crowns include all-porcelain (white), porcelain-covering base-metal, and all-metal. The all-metal crown is the cheapest and many insurance plans will pay only towards the cost of the all-metal crown. And again, that leaves the patient paying the difference between the two of these if they opt for the more expensive porcelain crown.
• And then there is the Cracked tooth: A cracked tooth can be repaired using filling material or a crown. If the patient and dentist decide on the crown, which is the costlier option, the plan will pay the allowance for the filling and the patient again has to pay the difference between the filling and the crown fee.

So now that we know that costlier services aren’t always reimbursed at the full coverage amount, lets talk about how to prevent upsetting a patient with a much higher bill than they had expected if it downgrade occurs.

This would be by obtaining a predetermination of benefits before the patient comes in for the service. The best way to go about getting a predetermination of benefits is to send in a claim asking for a pre estimate with the proper dental codes, the cost, the teeth that are involved along with the relevant x-rays. The insurance company will review everything that you sent and then determine if the procedure is eligible for reimbursement and they will also state on it if any downgrading will apply.

So, with the many challenges associated with dental billing and coding, many practices are opting to outsource these tasks. Experienced dental billers will be knowledgeable about CDT and if necessary, the ICD codes as well as payer rules and guidelines. They can help providers submit error-free claims and ensure optimal reimbursement. These companies also have dental insurance verification specialists who can confirm patient coverage and benefits prior to treatment as well.

And that’s it. I hope this helps, but always remember that documentation and a thorough knowledge of pay regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.
Thanks for listening in.