As you’re fully aware by this point, dentistry is one of the many specialities of healthcare. Routine dental care is not only essential to our oral health, but also our overall health too. Unfortunately, insurance treats dental care differently than it does other forms of healthcare. Dental insurance plans work a bit differently than the other kinds of health insurance, and often, they do not cover the entire cost of a patient’s treatment. This can be a tricky issue to navigate. It causes stress for both the patient and the dental clinic team, especially when it is not properly handled or communicated.
Dental insurance typically covers preventative care (like cleanings and checkups), basic procedures (fillings and extractions), as well some portion of major procedures (like root canals and crowns). However, the specifics of what is and what is not covered can vary widely depending on the insurance plan that the individual patient has.
Your duties will certainly include the handling of insurance claims. You will face both the patients who are seeking to cover the costs of their treatment with insurance, as well as the insurance companies themselves. This makes developing a strong understanding of the ins and outs of dental insurance especially vital to your success.
This module will encompass the most important aspects of dental insurance, as well as the specifics on how to work with insurance companies to submit claims. By learning from this content, you will be well-equipped to advocate for your patients’ best interests when helping them seek insurance coverage.
CDT (Current Dental Terminology) codes are a set of codes that are used in the dental industry as a standard coding system that identifies specific dental procedures and services. These codes are maintained by the American Dental Association, and are recognized by insurance companies to help ensure that dental services are accurately reported and reimbursed.
It is highly recommended that you take note of CDT codes and internalize them. Over time, you will come to learn them as if they are a separate language. However, this takes time! In the meantime, please look over the list below of the different CDT code categories. Feel free to write them down if it helps you learn quicker.
Different Types of Dental Insurance
Dental insurance is a complicated topic not only because of how it works in general, but also because there are many different kinds of dental insurance plans available. Understanding the differences between these plans is the only way that you can be best prepared to assist patients with their coverage and billing needs, especially since every patient is different, and will have a different plan according to the factors specific to their lives. We’ll break this down in the easiest way possible. It’s a great idea to take notes as you go through this module. While it might be especially hard to grasp concepts such as those related to insurance, writing down key terms and information in your own words in a short and memorable manner will make a huge difference in how quickly you are able to grasp the information.
There are also a few other types of dental insurance that do not fit into the categories above. For example, discount dental plans are not traditional insurance plans, but offer discounted fees for dental services from participating providers. These plans usually have an annual fee, and in exchange, patients will pay a discounted fee for each service they receive rather than receiving full or complete coverage.
Direct reimbursement plans are offered by employers as an alternative to traditional insurance. This plan means that the employer reimburses employees for a portion of their dental expenses, up to a predetermined limit.
Exclusive provider organization plans (EPOs) are similar to PPO plans, as they also have a network of dentists who offer discounted rates. However, there is no coverage for out-of-network care, so patients will have to stick to in-network dentists in order to receive their benefits.
While every dental practice is different, and the insurance that they accept will be determined by the demographics of their patient base as well as their location, there are a handful of prominent dental insurance providers that you might already be familiar with. The majority of the most popular insurance providers supply both indemnity and managed care plans, such as Delta, MetLife, Cigna, United Healthcare, and Aetna.
In-Network Dentists vs. Out-of-Network Dentists
In-network dentists have a contract with a specific dental insurance provider to provide dental services to their policyholders at a discounted rate. This means that the dentist has agreed to accept the insurance provider’s payment as payment in full for the services that they provide.
Out-of-network dentists do not have a contract with the insurance provider, and are therefore not obligated to provide services at a discounted rate. This means that the patient may be responsible for paying the difference between the dentist’s fee and the amount that the insurance provider is willing to cover.
Whether or not your practice is in-network or out-of-network depends entirely on the insurance plan that an individual patient uses. This means that it’s essential to understand how to navigate both of these different scenarios.
Anatomy of a Dental Insurance Plan
Harnessing the task of understanding the different types of dental insurance is one thing, but on top of that, it is important that you understand the anatomy of an individual dental insurance plan, too.
Always keep in mind that every dental insurance plan is different, so it is crucial to review the specific details of a patient’s plan before providing any estimates or discussing finances at all. By understanding the anatomy of a dental insurance plan, you will be well-equipped to help your patients to maximize their benefits and make informed decisions about their dental care.
Explanation of Benefits (EOBs)
Oftentimes, while working with dental insurance companies you will encounter an Explanation of Benefits (EOB). An EOB is a document that details the insurance company’s payment or denial of a dental claim. It will provide helpful information about the patient’s specific benefits, how much the insurance company paid, and also how much the patient still owes, if anything.
Your dental practice will have its own unique way of storing and handling patient EOBs. These methods are often determined by state or local dental association requirements, so as to better protect patient confidentiality.
There are five things that you will find in a patient’s EOB:
- Claim information, or what was submitted by the dental office.
- Service and coverage information, or in other words, the details of the patient’s dental insurance plans and the benefits that they are owed by it.
- Explanation of whether the claim was paid, or whether it was denied.
- Patient identifiable information such as policy number, group number, date of birth, and more.
- Details on resubmissions needed, if applicable.
Some items might look confusing at first for those who are newer to dental terminology. Here’s a breakdown of common terms you might see on an EOB, and what they mean:
EOBs are an important factor to understand when learning how to work with dental insurance companies. By working to understand EOBs properly, you will be able to ensure that your practice receives the payment that it is due and that the patients better understand their benefits and the limitations of their insurance, as well as the balances they may owe. This will work wonders with preventing financial surprises and keeping patients well-informed, and therefore less upset or stressed about the financial aspects of their treatment.