Dental Administration 101

1. Dental Administration 101 INSTRUCTOR Robbie Heath | 919 271 8863

2. What is Dental Insurance • Coverage for individuals that provides assistance with paying for the cost of dental treatment • Medical designed to cover costs associated with diagnosing and treating medical illness • Dental designed to provide coverage for preventative dental services-Patients assume larger portion

3. Group Dental Plans • Dental benefits sponsored by an employer • Insured- Employer pays a portion of monthly premiums to an insurance company on behalf of the employee. Insurance company pays providers • Self-funded- Employer collects premiums and invests the funds. Dental claims are processed and paid by the employer to the provider

4. Preferred Provider Organization- PPO • Patients have a choice in choosing providers but benefit most by using an “in-network provider” • In Network • Insurance 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 Network • Refers 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

5. 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

6. 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

7. Who is Involved? • 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

8. 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 plans • Pays approximately 50% of the bill to providers • Participating providers must write off the remainder bill for patients under the age of 18 • Adult patients are only billed $3.00 per visit • Strict rules regarding allowable procedures

9. 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

10. 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

11. 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 • Preventative Services usually are not subject to a wait period • Basic restorative services are usually subject to a 6 month wait • Major services may include oral surgery, prosthodontics, periodontics, and endodontics and usually are subject to a one year wait

12. 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

13. 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

14. 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

15. Three Levels of Coinsurance Preventative & Diagnostic Exams, Prophies, X-rays, Sealants, Flouride Basic Restorative Fillings Perio, Endo, and Oral Surgery Vary by Plan Major Services Crowns, Dentures, Partials, Implants, Bridges

16. Services Particular to the Individual Provider or Group • Sealants & Flouride treatment coverage and age limitations • Debridements • Buildups • Implants • Nightguards • Nitrous Oxide (N2O)

17. Other Important Benefit Information • Frequency Limitations • Describes how often a particular service is covered by a dental insurance plan. • Exams • Prophy • FMX/Panorex • Bitewings • PerioMainanence • Scaling and Root Planing • Fillings • 6 months vs 2 per calendar year

18. 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

19. 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

20. 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

21. 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 • Predeterminations • Itemized 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

22. 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