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Want to Bill Medical Insurance in Your Dental Office? Learn the Basics First

Want to Bill Medical Insurance in Your Dental Office? Learn the Basics First
Christine Taxin

At Links2Success, we help dental practices learn to bill medical insurance for medically necessary procedures. Billing medical insurance helps your patients afford necessary treatments and helps you expand your practice. Before you jump into medical billing, it helps to understand the basic kinds of medical insurance and how they pay claims.

 

Most dental insurance plans are fairly consistent in terms of payouts and benefits no matter who provides them. Medical insurance plans are more diverse, and the same administrator may offer many different types of plans.  Depending on the plan, all or part of a claim may be paid, your patient may or may not need a referral, and the claims submission form may vary.  There are six main medical plan types that dental offices are likely to encounter.

 

Indemnity

Indemnity insurance is also known as “Tradition Medical Insurance.” It used to be the main type of insurance on the market, and some companies still offer indemnity plans.  In an indemnity plan, there is no network. Patients can go to any provider who meets their needs.  

Indemnity plans work by dividing the cost of a service between the patient and the insurer. For instance, if a patient has a 20/80 indemnity plan, she pays 20% of the cost of a procedure, and the plan pays 80%. For most procedures with an indemnity plan, each provider sets his own rate. However, some indemnity plans do cap the maximum allowable rate for procedures.

 

From a provider perspective, indemnity plans are the easiest to bill. They tend to pay out more, wrangle over costs less, and have the easiest claims submissions process.  However, these plans are also expensive for employers and individuals, so they’re becoming less common as premiums rise.

 

PPO

A PPO, or paid provider organization, gives patients the freedom to choose doctors without referrals. However, out-of-network care is often much more expensive than care from providers within the PPO’s networks.  PPO members usually don’t need referrals to see specialists, but may need to request pre-authorization in order for certain treatments to be covered. However, if a patient forgets to get pre-authorization for a medically necessary procedure, some plans will give them “retroactive preauthorization” and cover the procedure anyway.

 

Different PPOs have different covered procedures and conditions, so be sure to consult with the insurer before discussing costs with a patient.

 

HMO

A HMO, or Health Maintenance Organization, only covers care from in-network providers. Each patient chooses a primary care provider (PCP) who acts as a gateway to other medical providers. In order to see a specialist, an HMO member must get a referral. However, HMO plans often make it difficult to get referrals.

 

HMO plans are very inexpensive, but it can be difficult to get them to pay for medically necessary treatments, especially from out-of-network providers.

Point of Service Plan

A Point of Service plan functions like a blend of a PPO and an HMO. Patients pay HMO rates when they stay in network, but the plan acts like a PPO when they go out of network. Point of Service plans often cover preventative care. The policy on referrals varies from plan to plan.

 

Tricare

Tricare is a plan used by active duty military service members and their families. Tricare families must see in-network providers for medical care. However, many dental offices are enrolled as Tricare providers.

 

Medicare

Medicare is a federal program for people over 65 and people with certain disabilities or chronic conditions.

To provide services for Medicare patients, you must be enrolled as a medical provider and have the appropriate identification numbers.  Medicare has strict rules about documentation to prove medical necessity, and the forms associated with it are fairly complex. Medicare also reimburses providers at a lower rate than most other plans.

 

With Medicare, if you fill out forms improperly, you may face severe penalties including large fines and even jail time. It’s important to receive adequate training before you bill Medicare for medical procedures in your dental office.

Basic Rules for Dealing with Medical Insurance in Your Dental Practice

Remember, every plan is different. Plans can have the same ‘brand name,’ such as Anthem, yet cover different procedures in different ways. In addition, coverage may change from year to year under the same plan. Always check with insurance before you give your patients a cost breakdown on a treatment plan. Otherwise, you may give them an inaccurate idea of what insurance will pay.

 

Medical coding, documentation, and claims is a more complicated process than dental insurance billing, so take the time to train your staff before you begin. However, don’t let the complexity weigh you down. With a little bit of help, you can learn how to help your patients better afford necessary treatments and improve their oral health.

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