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Payment Considerations with Dental Benefit Plans

April 20, 2023 319

If you choose to become a participating provider in dental benefit plans or accept assignment of benefits from plans, it is important to carefully read and understand each plan’s payment terms for both the patient’s portion and the dental benefit plan filing and reimbursement. Not only should you and your financial staff understand the terms, but it is critically important to be able to communicate the terms to your patients. Dental practices have the unique opportunity to educate patients on their dental benefits which can help reduce miscommunication and disgruntled patients.  Many patients are under the impression that dental practices determine the patient’s payment portion and do not understand that dental benefits are determined and arranged by employers and the dental benefit plan. The following are financial considerations and recommendations for patients with dental benefits:

  • If you are a participating provider with a dental benefit plan, it is necessary to collect the patient’s portion (copay). It is recommended that you collect this portion before or at time of service.
  • If you are not participating with the dental benefit plan, you must decide if you are going to have patients file their own claims or accept assignment of benefits. Be aware that some dental benefit plans do not accept assignment of benefits when a patient sees an out-of-network provider and you should advise patients that they will be responsible for paying for all treatment at time of service. Whichever route you choose, make the process clear to the patient and include your practice’s policy in your financial consent form.
  • If you are not a participating provider with the patient’s dental benefit plan and you choose to offer a courtesy for payment in full at time of service for patients with dental benefits, the courtesy must be applied to the entire cost of treatment. Therefore, when you file the claim with the dental benefit plan, the courtesy is applied to both the dental benefit plan portion and the patient’s portion. Typically, payment courtesies are not applied (or are reduced) to patients with contracted dental benefits, as most practices are already offering a reduction in the practice’s fee schedule as part of the contract with the plan, but if a discount is given, it must be reported on the claim form the same way.
  • Make it clear to the patient that the dental benefit plan estimate is simply that – an estimate. Because there is no guarantee that the reimbursement will match the estimate, it is wise to over-estimate the patient’s portion (copayment) by 10 percent. This way you can refund the patient if the reimbursement does match the estimate rather than being placed in the position of collecting the additional amount from the patient. This is also easier to explain to a patient — who would not prefer a refund over a bill? Here is a great way to explain this to your patients, “We contacted your dental benefit plan prior to your appointment and were able to get an estimate of your benefit for this treatment plan. This is a round figure, sometimes the company pays more and sometimes they unfortunately pay less. We work very hard to maximize your dental benefits and will provide you with a refund if we receive more than the estimate. With that said, if there is an unpaid balance after receipt of payment from the dental benefit plan, the patient is responsible for the difference.” If you are participating with the patient’s dental benefit plan read your contract before putting this plan of action into play as your contract with the plan may not allow you to collect over the patient’s estimated copayment.

Managing Dental Benefit Plan Accounts

Practices that participate in a significant number of dental benefit plans often expect the practice’s accounts receivable to be higher and extend into the “over-90-day” category. Although dental benefit plan A/R is processed and collected differently than patient accounts, it is possible to set up a system to manage dental benefit A/R and collect on the accounts within a reasonable time frame.

The following are recommendations for managing dental benefit plan A/R:

  • Because payment is processed and received quite differently with dental benefit plans than patients, it is important that the dental benefit A/R be separated out into its own aging report or tickler file.
  • Dental benefit A/R should be reviewed on a weekly basis and monitored very closely. The staff member responsible for tracking claims should know the details about every dental benefit claim account overdue by 90 days or more. There should be a reason and the staff member should be watching it closely.
  • The practice should utilize electronic claims filing for as many claims as possible. This expedites the claim filing process and reimbursement from the plan.
  • To expedite follow-up calls to dental benefit plans, sort the A/R report by plan rather than by the patient. This way you can follow-up on all claims for the plan in one phone call.
  • Also, not that most plans have portals that will often get you an answer much quicker than a phone call will.
  • Practices that utilize electronic claims filing and file claims daily should be able to control the A/R (over 90 days should represent no more than 7 percent of total A/R).
  • When reimbursements fall short of the estimated amount, the patient should be billed or charged for the unpaid balance immediately. It is important to not let this amount sit, as a patient may quickly lose motivation to pay as more time passes.

When you recruit for the financial staff person for your practice, you should design the role and job descriptions around the financial consultation and collecting balances before or at time of service. Many practices will even tie certain incentives or bonuses to the financial coordinator position as a motivation to keep collections high and A/R low. The entire team should know the practice’s financial objective and should know how this goal impacts their roles. After all, practice collections have a significant impact on cash flow, which in turn determines whether the practice has the funds for payroll. You cannot give your dental assistant an “I owe you” instead of a paycheck, so why offer that option to a patient?

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