Week 4 PP Flashcards
Different forms of Dental Insurance Plans
-Traditional dental insurane plan (employer plan)
-Managed care dental insurance plan (individual plan)
-Government programs
Traditional Insurance Plan / Idemnity Plan
A plan that helps with the cost of dental care.
Considered “fee for service” and come with limitations and co-payment options.
The patient has an annual limit on coverage for dental spending and specific coverage limits that may apply to specific procedures.
Managed Care Dental Plan
-Method of providing low to medium coverage to everyone
-The type, level and frequency of treatment can be limited
-Disease prevention is encouraged
-Plan could also control the level of reimbursement for services
Preferred Provider Oganizations (Dental PPOs)
Tehcnically a closed panel type of plan
- Closed network plan where individuals must visit a preselected or assigned network dentist to receive benefits
- A dentist may join a PPO in hopes of attracting new patients
-Patients are charged the dentist’s usual fees
-SAIT’s student dental plan is like this. Students can see a preferred provider or a dentist of their choice
Dental Benefits Maximum = $750 per her 80 % basic coverage
Exclusive Provider Organizations (EPOs)
- Form of closed panel dental insurance
- Patient’s are offered NO option other than receiving their treatment from a dentist who is a member of the plan’s network of providers
- University of Calgary student insurance
- Maximum of $750 per year
- Note that these benefits can only be used at Dental Choice clinics in Alberta (6 offices in
Calgary). Services performed at other dental centers will not be eligible for reimbursement.
Direct Reimbusement Plan
- Self-funded program
- Individual is reimbursed by their employer based on a % of dollars spent for the dental care provided.
- Can seek treatment from the dentist of their choice.
- No insurance company involved.
- Employee pays the dentist and the employer reimburses the employee a portion of the
expense. - Amount reimbursed is decided by the benefit design established by the employer.
Basic Procedure Coverage
Benefits covered to maintain and preserve the oral structure. Procedures covered may vary, but commonly include..
✓ Prophylaxis
✓ Scaling
✓ Fluoride (usually has age restriction)
✓ Restorations
✓ Extractions
✓ Root Canals
✓ Radiographs
✓ Study Models
✓ Biopsies
This is usually the area with the higher percentage of coverage. Most common is 80% or 100% coverage of the dental insurance company’s fee guide.
What is Major Coverage?
These are benefits for more extensive treatment. Procedures covered may vary, but commonly include:
✓ Crown
✓ Bridge
✓ Dentures
✓ Complex Oral Surgery
✓ Periodontal treatment (surgeries)
These procedures are usually covered at a lower percentage of coverage. Most common is 50% coverage of the insurance company’s fee guide.
What is the subscriber?
The person who carries the insurance and also the person receiving the treatment
What is a Dependent?
child or spouse of the subcriber
Who is the Carrier?
The insurace company who pays the claims and collects premiums
Who is the Group?
The employer that purchased or arranged insurance as a benefit
Who is the Provider?
The dentist or hygienist who performs the service
3 Most Common Methods of Calculating Fee-For-Service Benefits
- Usual, Customary & Reasonable (UCR Fees)
- Schedule of Benefits
- Fixed Fee Schedule
UCR Fees
Usual: Refers to the fee that the dentist charges private patients for a given service. Fees are determined by the dentist and are the fees routinely charged by the practice. A dentist will confidentially file their fees with dental insurance companies. This information (prefiled fees) is sued by the insurance company to establish the customary fees for the area.
Customary: fee that is within the usual range of fees charged for the same service by similary trained dentists in the same geographical area. Established by comparing pre-filed fees of dentists in the area.
Reasonable: fee that is considered justified by special circumstances necessitating complex treatment (where dentist charges more than the usual fee wheven to a private patient). An example would be a complicated extraction. Dentist would need to submit written documentation explaining why the unusual fee is required.
In an UCR system the patient is responsible for…
the difference between the insurance payment and the dentist’s fees
- limitations of the policy will influence the amount the dentist receives from the carrier and the amount the patient must pay
Limitations and exlusions
Dental plans do not usually cover all procedures
Each plan contains a list of conditions or circumstances that limit (number of procedures permitted udring a time period; 1 cleaning per 6 months) or exludes services from coverage (no orthodontic treatment)
Table of Allowance/ Schedule of Allowances:
-List of fixed amounts that the carrier will pay towards the cost of covered services
-Is not related to the dentist’s actual fee schedule
-Created by the insurance company (Eg. blue cross has its own fee guide)
Patient is responsible for the difference between what hte Carrier will pay and what the dentist charges
What is a Fixed Fee Schedule?
An established fee for any treatment received by the patient.
- Often lower than average fees
This is used for Government Plans - (Alberta Child Health Benefit, AISH, Non-Insured Health Benefit - includes all registered First Nations & Inuit persons)
Dentist must accept this fee and cannot bill the patient the difference
*Some programs eligibility can change month to month so verification of coverage must be done frequently
Determining Eligibility
When an employee starts a new job there is typically a waiting period before benefits become effective (employee pays into the benefits for a specified period of time)
If an employee retires, quits, or is laid off the insurance coverage will typically terminate within 30 days of the change
Determining Benefits
The employer purchases benefits for their employees and negotiates the limitations and benefits of the plan
The insurance company is only responsible for covering the level of treatment outlined in the employer’s plan
This information can be found in the benefits booklet
If possible, the patient should bring their booklet to their first appointment or review it online prior to dental treatment
Dental Insurance Limitations
-There are several factors that influence the level of benefits that the beneficiary is eligible for and the amounts they must pay as a share of these costs
Least Expensive Alternative Treatment - LEAT
This is a limitation in a dental plan that allows for benefits only for the least expensive treatment.
For Ex: a patient needs to replace a missing tooth
Treatment options: Fixed bridge for $4000 or partial denture for $2500
Under LEAT the carrier will pay the benefits for a partial denture only. If the patient decides on the fixed bridge, the patient MUST pay the difference in cost
Dual Coverage
-Patient has dental insurance coverage under more than one plan
-Steps to make sure the benefits are paid
Determining Primary & Secondary Carriers
Which insurance company pays first and which one pays second
When the patient is the insured - their insurance company is the primary carrier.
Their spouses insurance would be their secondary carrier
When spousal coverage is in place for patient’s with insurance of their own, their insurance must be filed first
Dual Coverage Birthday Rule
Explains which insurance company is the primary carrier when both parents have dental insurance
The rule stipualtes that when a child is covered under both parent’s plans the plan of the parent who’s birthday (month and day) falls earlier in the calendar year is billed first.
Other factors are involved when parents are divorced or separated or when step parents are involved. Offices need to work with the parents to define the billing in these situations. (do not worry about this for exams)
Coordinations of Benefits
The patient or dental office will receive payment from both insurance carriers but the total received can not exceed 100% of the actual dental expense
The fee is $200
Primary carrier will pay $105
The secondary carrier will pay no more than $95
no matter what benefits the secondary carrier will
pay for the service.
The patient or office will not be reimbursed for
more than 100% of the cost.
Nonduplication of Benefits (Benefits less Benefits)
a provision that releives a carrier from responsibility for paying for services covered under another program. Reibursement is limited to the higher level allowed by the 2 plans rather than to a total of 100%
Ex) A fee of $250 is charged.
The primary carrier will allow $175 for this service.
The secondary carrier allows for $190 for this service. In this situation the primary carrier pays $175 and the secondary carrier will only pay $15 to equal the $190 that they are willing to pay for that service.
* Many patients are unaware of this clause and may need to have it explained to them.
What are Dental Procedure Codes?
- Is a system of categorizing dental services
-Each dental service has a unique 5 digit number
-Each province can have slightly different codes; however they are similiar enough for Canadian Dentists and insurance companies to use consistently - Allows Canadian dentists to standardize their work and also allows governing bodies to regulate how dentistry is performed and the amount the dentist can charge for the service
10 Basic Categories for Dental Procedure Codes:
- Diagnostic services
- Preventative services
- Restorative Services
- Endodontic Services
- Periodontal Services
- Removable Prosthetics
- Fixed Prosthodontic Services
- Oral and Maxillofacial Services
- Orthodontic Services
- Adjunctive General Services
Dental Procedure Codes & Units of Time
The last number can refer to the number of units of that service you received
Ex) 11111 - 1 unit (15 min) of scaling
11112 - 2 units (30 mins) of scaling
The code can also indicate the type of filling
material being used, tooth being worked on and
the surfaces involved.
Provincial Fee Guides
Every Province/Territory has its own Dental Association and each association issues a fee guide for the dentists who work within that province or territory
Sets the norm for the prices that all provincial dentists use. This fee guide is a suggestion of how much each dentist should charge for those procedures. Final amount is determined by the dentist (can charge as much or little as they want). The patient is responsible for any fees that their insurance company doesn’t pay
Claim Forms can be filed in 2 ways..
- Paper submission (mailed to insurance company)
- Electronic submission
All Claims require the following information:
- Patient & Subscriber indentification
- Dentist identifaction
- Treatment details
All parts must be completed accurately before
submitting to the insurance company
If submitted incorrectly the insurance company will
not process the claim.
Dental Claim Guidelines
-Transimt claims on a daily basis
-Must keeep a record of each claim that was submitted
-Transmission problems an occur so claims may need to be submitted again
-Report is generated weekly or monthly to ensure all payments have been received from the insurance company
What is a Signature on file?
Signature authorization form or a blank
insurance form can be signed by the patient and when the claim form is completed “Signature on File” can be used in place of the policy holder signature.
***Assignment of Benefits means…
When a dentist submits the claim form to the insurance co. the payment is to be made to the dentist
- When cheque or EFT is received by DDS, balance not covered by insurance is then billed to the patient
**Non-assignment of Benefits
-The patient pays the dentist the full amount charged
-The dentist will submit an insurance claim with payment to go directly to the patient
Estimates
-Provided to the patient with information regarding treatment
-A copy is given to the patient and a second copy is kept in the patient’s chart
- Can compare 2 treatment options
-The estimate helps the patient make an informed fincancial decision with their dental treatment
- An Estimate is NOT sent to the insurance company
Pre-Treatment Estimate
Sending a pre-authorization (an estimate from the insurance company) is the only
way to be sure that the treatment recommended is covered.
The insurance company will process the preauthorization in conjunction with dental consultants to approve coverage.
The information is processed based on the current coverage balances. This information is typically sent to the patient. Authorization is only good for a certain period of time.
What are Pre-Authorizations?
Some insurance co. require you to send a pre-auth for major or basic treatment over $300
This is a benefit to both the dental office and the patient. Once the pre-auth comes back to the patient and the office will know the exact amount that will be covered and what the patient is responsible for, up to the yearly maximum.
Insurance company will cover expenses up to a certain time period and as long as benefits are still available. (Ex. Pre-auth is good for 4 months)
Insurance Fraud - how it affects RDAs
-Submissions must be accurate and honest
-Even if it’s the dentists idea to submit a fraudlent claim the business assistant or dental assistant can’t escape liability by claiming ignorance
What does Insurance Fraud include?
-Billing for services not provided
-Charging fees on a claim form to obtain a higher payment
-Disregarding a co-payment or deductible and accepting only the insurance payment and writing off the difference
What is the annual maximum?
amount of money the insurance company will pay for a patient in a specific benefit period (calendar year)
What is dual coverage?
patient has dental coverage under more than 1 plan
What is primary carrier?
insurance company (carrier) that pays first
What is a secondary carrier?
insurance company (carrier) that pays second
What is the birthday rule?
When a child is covered under both parent’s plans, the plan of the parent whos birthday falls first in the calendar (dd/mm) year is billed first
What is a benefit year?
12 month period of the dental contract (not always calendar year). most patients have a maximum allowable per year
What is covered services?
a dental service that is payable under the terms of the benefit program
What is a deductible?
amount of $ each enrollee or family must pay before insurance will pay for covered services. Ususally $25 to $50
What is EOB?
Explanation of Benefits
-When there are 2 plans the secondary insurance will want to know what the primary insurance plan paid
What is a pre-existing condition?
an oral health condition that exisited before a person enrolled in a dental program
What is a Schedule of Benefits?
a list of dental services covered by a dental benefits program
What is a waiting period?
Period between the start of employment and the date that the employee becomes eligible for benefits. If a subscriber is fired, laid off or retires the coverage will terminate within 30 days of the change in employment
What is Coordination of Benefits?
patient or dental office will receive payment from both insurance carriers but the total received can not exceed 100% of the actual dental expense
What is Nonduplication of Benefits (benefits less benefits)?
a provision that relieves a carrier from responsibility for paying for services covered under another
program. Reimbursement is limited to the higher level allowed by the 2 plans rather than to a total of 100%
