Everyone wants to take care of their teeth. However, there are many individuals who choose to pay out of pocket to get dental care services, which means they either do not have any active dental insurance plan that offers low-cost dental care or they are willing to choose the dentist who does not have a contract with their insurance provider. Choosing out of pocket to get dental care services means that the patient is responsible for the bill of the services they have availed.

Dental care can be expensive especially if patients prefer to take regular visits to the dental Office by paying out of pocket. This can also be possible that a dentist can charge whatever they wish because they do not have a contract to charge the amount fixed with your insurance provider. Another difficult aspect of paying out of pocket for dental services is that dental offices want to get the full payment at the time they have provided the services instead of getting it in installments. 

In cases, when a patient wants dental care unexpectedly for a chipped tooth or other situations then it can be difficult for a patient to pay out of pocket for the cost of services in a short time. Moreover, having a family and paying out of pocket can multiply the out-of-pocket cost.

Why opt for insurance coverage instead of choosing to pay out of pocket for dental care?

The fee required for dental care has been increasing day by day. These dental care costs are more when you pay for multiple dental procedures availed by your family. At the same time, skipping dental care can put a person at serious oral health risks and even lead to other health issues. However, choosing to pay out of pocket can lead to unwanted high costs for dental services and be an extra burden on finances. Thus, dental insurance becomes important and as most health plans do not provide dental coverage so dental insurance needs to be purchased separately.

Like all health insurance plans, dental insurance plans also have both in and out network dentists. If individuals prefer to pay in the network, then they need to pay less as dental insurance covers most of the charges. However, if the person prefers to avail services from a dentist who is out of network then they need to pay a little higher cost. Depending upon the dentist you choose, your dental care office may need to take pre-approval for the dental services they are offering to you. Also, many dental offices prefer to charge differently for preventative, basic, and major services so get all information before you choose a dentist from in-network or out network.

Why do patients need to pay out of pocket to get dental services?

Usually, when an individual is covered by a health insurance plan, then they should use it to see their dentists. However, there are some instances when a patient pays for dental care out of pocket to get dental services such as:

• You have a long time to pay for the deductible. After having dental coverage, still some patients prefer to pay out of pocket. Deductible means patients need to contribute some amount every year before starting to pay for the dental care costs. However, if a patient has a long way to pay the deductible then they prefer to pay for out of pocket. Paying out of pocket sometimes charges less than deductible costs. However, it should be noted that paying for out of pocket does not mean paying a deductible and thus it can even cost more when you pay deductible after some time. Thus, it is best to pay the deductible once a year and go for dental care services covered under in-network.
• Some patients want to avail dental care services that are not covered under in-network. However, the best way is to ask your dental care provider to offer you some discounts that can save some of your money.
• Sometimes, the patient has already hit the annual maximum amount, and still, they want some dental care services this year. Many dental insurance programs have set the maximum dollar amount that they provide on a yearly basis and for the rest, you need to pay for the rest of the services. Once the yearly plan resets, your services will be re-covered by your dental care provider.

With an insurance plan, you get a comprehensive package covering both routine preventive care and other important dental treatments. Also, the dental insurance plan can motivate some to get their regular dental care and get treatment services, after all the dental insurance plan will pay for it. A good dental insurance plan can even save you in the long run. Thus, it is best to have active insurance coverage instead of paying out of pocket to get dental services.

Eligibility date or billing date is the recurring monthly date on which you are charged the monthly insurance premium. The dental eligibility verification date is established on the day the application is submitted and approved. It also acts as the date for recurring billing for each month. 

On the other hand, the effective date is the date on which the benefits of the plan come into effect. It varies from plan to plan as well as depends on your insurance carrier. In most cases it is usually the next day after enrollment. 

As a result, once a person reaches their effective date of their dental coverage, they can start using the benefits covered in their policy. 

In what case can patients not use their benefits even after the effective date has come into effect ? 

It can easily happen that a person reaches his/her effective date but is still unable to receive the benefits with respect to the dental treatment he/she wants. This happens when their insurance carrier has enabled a waiting period on their policy. The waiting period refers to the amount of time one has to wait for before the person who has taken the insurance plan can start using the services covered in the plan. This is why it is important to check for the waiting period duration in your plan even after the effective date has come into action. It is because if you get some treatment done, say routine examination or a more expensive one like tooth extraction then these will not be covered by your insurance plan if the waiting period has not been waived. 

Moreover, if the waiting period is of a certain time then it is advisable to ask the dentist for a rough estimate of the cost of the treatment you seek as it can easily prove more costly to delay treatment.  

Health insurance plans generally function on a network of coverage basis. They only provide reimbursements for service providers and hospitals they have agreements with or who are listed under their plan coverage. These agreements are based on terms related to discounts and offers. Services provided by health care professionals other than these are referred to as “out of network” services and the reimbursement claims made for these services are ‘Out of Network’ claims. While some insurance companies or plans do provide out-of-network benefits, this is not the norm. 

If a particular dental care provider’s service is not covered by a health insurance company or is an ‘out of network’ service, the patient might have to pay the entire bill or a large part of it, even with an existing health insurance plan. 

Why do insured patients go for Out-Of-Network dental professionals? 

• Out-of-network by preference
  When a patient knowingly and deliberately prefers an out-of-network dental care provider due to recommendations, word of mouth, positive work ethic, successful previous operations, or other personal reasons, they may be willing to pay extra if needed to avail these services. 
• Negligence or confusion
  A patient may neglect the terms of service of a dental insurance plan due to ignorance or may get confused due to excessive foggy paperwork or unclear communication. As a result, they may unintentionally avail services by out-of-network dental professionals. 
• Services offered by different dental professionals.
  It is likely that an ‘in-network hospital that a patient goes to also has dental service providers that are out of coverage of the patient’s insurance plan. Being unaware of these intricacies, a patient might avail of dental services from an out-of-network dental service provider. 
• Extra services
  A patient may go out of network when the dental insurance company denies taking responsibility for unavoidable extra services, like private or air-conditioned rooms, due to unavailability or excess capacity of regular rooms. 

It is the responsibility of dental professionals to ensure the patient insurance eligibility and make them aware about the out-of-network protocols to avoid any future hassles in revenue flow. 

Billing an out of network claim

If a patient gets in contact with the insurance company beforehand about an out-of-network service they wish to avail, a request to claim reimbursement can be submitted to the insurer. The dental insurance company may respond positively if the request seems credible. Negotiation abilities come in handy in situations like these. Consulting a dental billing company like Capline Dental for the same can be beneficial. 

Some insurance plans have an out-of-network payment cap. If the cap is not reached yet, the insurance provider may cover a portion of the expenses, considering that the deductible has already been met. 

A well-detailed claim must be submitted to the insurer to reimburse out-of-network claims. The reimbursement can be directed towards the patient or the dental care professional. The request must adhere to and include the following: 

• Copies of the receipts or statements that include: 
  • Patient’s name and personal details. 
  • Name of the doctor, office address, identification, etc. 
  • Date of Service. 
  • List of all services and diagnosis received by the patient with CPT codes and the amount paid respectively. 
• A thoroughly filled claim form. Incomplete forms with missing or inaccurate information will only delay the reimbursement procedure and can also lead to claim denials.
• On time claim submission. 

There is a limited period to submit the dental insurance claim. This period usually lasts up to twelve months from the date of service. Dental Professionals must adhere to these guidelines to avoid claim rejections.

Dental billing is one of the most essential parts of revenue cycle management (RCM). The process requires submitting a clean claim in order to get reimbursement of the rendered dental services from the insurance companies. In general, dental claims are submitted by filling ADA dental claim forms. This claim form is made on  the guidelines laid out by American Dental Association (ADA) and keeps on updating periodically. In a few cases,  CMS-1500 (medical billing form) can also be used to file dental claims. 

ADA Dental Claim Form 

ADA dental claim forms incorporate HIPAA standards for electronic dental claim transactions. 

General Guidelines: 

• The name and address of the payer (insurance companies or dental benefit plan) should be mentioned in  the standard #9 window envelope. 
• Every detail is mandatory unless marked otherwise on the form or CDT manual. 
• The full name of the individual has to be mentioned on the form wherever required. 
• The full name of the business along with the address and zip code has to be mentioned wherever  required. 
• The years in the mentioned date should be of four digits. 
• If the number of rendered procedures cannot be contained within the given number of lines in the  form, a separate form has to be filled with all the details. 
• COB (Coordination of Benefits): Dental claims submitted to the secondary payer should include EOB (Explanation of Benefits) to show the reimbursed amount by the primary payer. The same amount has to  be filled in the “Remarks” field. CDT manual contains detailed instructions for the completion of the same. 
• Diagnosis Code: Diagnosis codes are required for claim adjudication when certain treatment is required to  reduce the risk of a patient’s oral and systemic health conditions. Up to four diagnosis codes can be  used for each procedure. 
• Place of Treatment: As per HIPAA standards, a 2-digit code is used for a professional claim. You can find  the full list of these codes on www.cms.gov 
• Provider Specialty: Different types of dental professionals have a specific code based on their specialty.  Additionally, a general code for the dentist can be used in the form as well. The codes can be found  at https://www.ada.org/en/publications/cdt/ada-dental-claim-form 
• The claim can be submitted for services rendered, pre-determination, pre-authorization, or Early and  Periodic Screening, Diagnosis and Treatment Program. If the claim is pre-authorized or pre-determined  previously, the pre-authorization/ pre-determination number has to be mentioned in the form. 

For a detailed description of the ADA dental claim, visit  

https://www.ada.org/~/media/ADA/Publications/Files/ADADentalClaimCompletionInstructions_v2019_2020.pdf?l a=en 

When is CMS-1500 form filled for dental claim submission? 

CMS-1500, which is also called HCFA-1500, is used when there is an overlap between medical and dental care  provided to the patient. Various treatments mentioned below are required to be claimed as medical claims rather  than dental claims. 

• Dental Trauma from an accident 
• Inflammation and infection. 
• Dental repair of tooth/teeth caused due to accident/injury. 
• Oral or periodontal surgery procedures 
• Dental disease caused due to cancer treatment. 
• Exams for orofacial medical problems. 
• Extraction of wisdom teeth, under certain conditions. 
• Extraction of multiple teeth at one time.
• Certain periodontal surgery procedures. 
• Consultation for and excisional biopsy of oral lesions. 
• Consultation and treatment for temporomandibular joint problems. 
• Infection that is beyond the tooth apex and not treatable by entry through the tooth. 
• Pathology that involves soft or hard tissue. 
• Procedures to correct dysfunction. 
• Emergency trauma procedures. 
• Appliances for mandibular repositioning and/or sleep apnea. 
• Congenital defects. 

Although dental professionals might have an option to claim such a procedure, in most such cases, medical  insurance is treated as primary payer while dental insurance is the secondary payer. In these cases, medical coding  (CPT codes) of the specific dental procedure is required to be filled in the medical claim.  

A dental professional and the biller should be well-versed with such policies and protocols. In various cases, the dental offices’ claim filing system does not have profound knowledge of filing medical claims. 

How to manage clean claim submission? 

Accurately filling the ADA claim form and CMS-1500 form requires in-depth knowledge of the procedures, dental  and medical codes, and insurance policy guidelines. At certain times, it can become a cumbersome process for  dental professionals to handle dental claims along with managing the efficient functioning of the dental office and  hospital. In most situations, the effort of handling both RCM (Revenue cycle management), as well as the dental office, takes a toll on the quality of service provided by the dental professionals as well as the revenue flow within  the system. To avoid such scenarios, most dental professionals these days are outsourcing dental billing companies  like Capline Dental Services which are not only reliable, but also have proven expertise to drastically improve the  revenue flow within the system. Capline Dental Services provides various services to dental professionals. 

Interactions between the practitioner and the patient-related to clinical examination, ongoing  treatment, present illness, prognosis, and the diagnosis are dental records. This record-keeping is  essential for good professional practice, yet sometimes it is quite challenging. Regardless of the record form  paper or electronic that is used by the practitioner to nurse dictation, the purpose is to record the communications between  different practitioners to cover a legal obligation for the reimbursement. Consequently, accurate and  complete documentation is an effective continuum of patient care. However, no system is perfect. Many different factors contribute to the creation of  unclear notes or obscure documentation. The components in particular can be the insufficient time to  interact as well as lack of adherence to compliance.  

What are unclear notes or obscure documentation? 

A typical question is what are unclear notes or obscure documentation? Before tackling a  documentation problem, let us understand the specifics of what represents poor documentation in  the first place. In the case of a practitioner using a particular dental record, it is poor documentation if it impairs patient  treatment or evaluation. For a coder, deficits in procedure and diagnosis codes can result in the same. Moreover, if the document lacks  completeness, clarity, and fails to convey a patient problem, if it lacks sufficient specificity to address patient safety that can compromise the quality of the rendered care it will be categorized as obscure documentation. 

For instance, if a practitioner is documenting oral lesions, he/she will need to include size, shape,  color, location, consistency, distribution, history, texture for the oral lesion. These specificities  will help in the treatment of the patients who need our help. The consequences of poor  documentation are significant, they can impact things like patient safety apart from having financial repercussions. 

Benefits of good documentation: 

• Effective patient care 
• Correct diagnosis and treatment decisions 
• Medical necessity diagnostic study 
• Clear communication between other practitioners that results in apt treatment plans and quality  care 

Factors affecting poor documentation
Know-how: First and foremost, insufficient information of the dental industry can result in poor  documentation. Due to the tight schedule, it becomes difficult to provide training to providers. They  document a lot of information, still leaving behind the usage of the words needed for the highest  level of specificity. Incorporation of a modified approach for proper documentation, does not happen  by chance. It requires education in the long run. 

Time-constraint: Another fundamental requirement is the time factor at play. The priority of every practitioner is  patient care, and with that obligation, documentation can sometimes take a back seat. The number of patients  that a particular practitioner is handling per day can lead to a tug of war, giving them  insufficient time to verbalize to document the same. Spending more time with patients can help with the documentation  problem. Generally, practitioners lack motivation due to missing incentives and system  prejudices. 

Copy-paste: EHR compliance is capable of accurate documentation, but only using copy and paste of  dental records with the same assessment can impair the original thinking. Some meaningful adjustments here and there are under compliance, but blatant use of copy and paste can easily miss out on different and essential patient conditions. 

Steps to handle the problem

• HIT integrated into teaching conveys to all practitioners about what does and does not work in the  documentation. Also, it explains to them the impact and importance of documentation on the  quality of care. 
• A well-qualified and dedicated team of professionals hired can work instead of disinterested or busy  practitioners in learning the EMR tool, which will eventually increase both the monetary as well as patient satisfaction rate. 
• Identify flaws in documentation with the help of experts to deliver quality dental care. 
• The  following things can prevent errors in the documentation. Experienced professionals check things like whether the document supports the medical necessity or not,  was the diagnosis and treatment adequate, were there any deficiencies, provide remedies through revisiting EMR, and check how was the care offered post-procedure to track  the outcome? 
• Perform a gap analysis on the education of practitioners and record reviews for their growth in the long  run. Addressing the complications and comorbidities motivates the practitioners to improve  documentation as they realize the severity and risk of mortality. 
• Seek help from administrators with experience in successful documentation that result in higher reimbursement  with quality patient care. 

According to research, once a patient leaves the office premises, the chances of collecting the  money from the patient comes down to nearly 36%. Sometimes the patients even avoid seeking  dental help due to the higher bill amount. As a provider, you can offer conditional discounts to the  patients on the bill. It will increase the chances of getting the payment on time and improve your client retention rate.  

Most of the practitioners will ask for the bill payments during or after the rendered treatment. Although, some dental offices will ask the patients to make the payment before their office visit, which later could likely not be a pleasant experience for the patients. It can affect them so much that they may not want to see the doctor again. Dentists offering payment plans can implement a few strategies that are likely to prompt the clients to pay their bills on time and leave the office with a happy face.

Looking at a bigger picture the strategy is to offer discounts to your clients. Practitioners can offer a discount of 15% on immediate bill payment or the dental offices can even provide one or a combination of several perks to the patient. For example, as a provider, you can offer the patient a discount of a certain  percentage on the final bill if they make partial payments before utilizing the rendered services. Let us not forget any relief in the expensive bills can be a sigh of relief for the patient because of which they are more likely to visit next time whenever they need any dental assistance. Also, it is crucial while you are explaining to the patients about the discount offer, you are at the same time able to convey the  message that the dental office understands and cares for their pockets too. While gaining the trust of the people you are going an extra mile to win them forever. 

Legal discounting procedures: 

Another thing is that a discount procedure offered to any patient can be more than just help as it can act as a strategy for getting timely payments. Sometimes a patient cannot afford dental aid, and as a provider, you may  offer discounts on humanitarian grounds. In cases like that, the insurer may raise questions against the  practitioner and the services. It may even be subject to professional misconduct if copayment  & coinsurance have been waived. Dental assistance may not always yield the desired outcomes. A lot depends on the  gravity of the financial condition of an individual. Insurance companies are more likely to doubt a caregiver's intentions  if a particular patient receives a heavy discount especially when other patients don’t. This is why it is important to convey the same to the  payer, along with the discount offer, to avoid any confusion or legal procedures later. 

Educating the patients: 

Sometimes patients who already have insurance plans will ask for discounts for the amount they  have to pay. In this case, with the revenue cycle lengthening and reimbursement shrinking, educate  patients about the deductibles they owe for the bill. An articulately and clearly expressed  fact may help the dental office avoid loss in their revenue. 

Be consistent with an approach: 

Every patient's financial condition is different and so is their approach towards collections. This is why in order to avoid a  haphazard approach attempting to offer discounts to the patients something well documented is required. A written standard procedure for financial relief, including individual circumstances and a range of income should be created so that no invoice goes unpaid.

Conclusion: Implementing the above points can help improve the revenue and timely payments from the patient's end. Yet, constant analysis and changes are required from time to time for quick fixes and  improvement of the revenue model.

With each passing day, dental care regulations are changing and so are insurance providers' models as well. A "fee for service" simply means that an individual is allowed to see any dentists, hospital doctors they wish to see. “Managed care” means a dental insurance plan that manages both the aspects of dental care: quality and cost of medical facilities. Its main aim is to provide insurance coverage to individuals by focusing on dental care management, which produces better results and healthy lives. To understand the difference between both types of reimbursement models, it is important to have detailed knowledge about both models that will help in figuring out the best dental care payment cycle management.

All about managed care and what makes it better?

Managed care refers to that group of insurance plans which are aimed at managing the two aspects of dental care, one is cost and the other is quality. If an individual belongs to managed care that means they will get medical facilities at minimum cost. Its main aim is to provide better patient outcomes by focusing on prevention and dental care management. With such a plan, an insurer needs to sign a contract with some dentists regarding the facilities they provide so that they will be at reduced costs. These dental care providers need to provide dental care facilities at minimum cost. Additionally, the dentists need to fix prices for medical care they provide and also try to reduce the costs by focusing on providing incentives like charging less for generic medicines rather than branded medications.

Some managed care providers provide cashless access for medical services to their patients which gives insurers a deep idea about the performance of dental benefits. It also allows an individual to choose, compare their dental care services and thus avail best of them. The main advantage of managed care is that it provides dental care services to people immediately when they consult with dental care professionals. 

Listed below are some of the benefits of managed care such as:

A managed care organization allows older persons wanting any surgery to choose medical services without paying cash at the preferred network. This allows the individuals to choose the preferred medical center by using a mile app with cashless hospitalization. Additionally, E-cashless also allows an individual as well as their family members to have full visibility on expected cost, the amount that needs to be paid out of pocket, and the amount covered under the policy.

Managed care organizations interact with different dental care providers about the rates of medical services. This way, dental care providers provide medical services at low cost and discounted rates. Also, these plans help to control the various price losses in case of hospitalization. All of these activities also help dental care providers to provide quality services to their patients without worrying about the revenue cycle.

Managed care organizations also interact with all stakeholders so that they can invest in the technology of hospitals for transformation. It also allows all stakeholders to join one platform to improve the access and quality of dental care delivery.

Managed care organizations play an important role in checking trusted and genuine beneficiaries who follow the terms and conditions of the dental care policy. New advanced MCO plans are a combination of professional expertise as well as technology that reduces the risk of fraud and abuse control.

Managed care organizations play an essential role in changing the lives of many dental care industries. With the help of deep knowledge of all stakeholders, an optimistic idea for the future, and leading technology, MCO can bring a revolutionary change in the dental care field.

All about Fee-for-service and its benefits:

Fee-for-service is also known as FFS, is a dental care payment model where dental care professionals are paid as per the number of treatments, procedures, services, and other valuable care they provide to patients. In FFS, medical professionals are paid by insurance companies every time the patients receive any type of medical service. In this case, dental care professionals are paid regardless of whether the services they provide are necessary for the patient or not. It is a traditional mode of payment that provides payment for every medical service separately billed. Dental care professionals favor FFS as they get the payment for every service they deliver as per the professional standards. As per this model, the patient needs to pay the doctor first. In this plan, the cost of dental care services is managed by the dental care providers or third-party payers. The quality of dental care services provided to a patient does not affect the incentives that clinicians will get. However, the disadvantage of FFS is that services are separately billed so the patient needs to pay more for unnecessary services.

The ultimate aim of selecting between fee for service and managed care is to access quality care by knowing the cost of treatment. There is no doubt that with the growth of dental awareness among people, there is an increase in demand in providing quality care to patients thus the dental industry needs to shift its attention to providing the best value-based managed care to their patients.

In Dental terms, restorative services refer to specialized procedures that help maintain, retain and maximize a healthy and fully functioning oral cavity. These work as preventive as well as corrective measures that help regain and cure any previous damages in the form of decays, cavities, missing, crooked, misaligned, crowded teeth, or any other accidental injuries. These procedures are also pursued if the patient is unsatisfied with the appearance of their teeth. 

Restorative dental services include procedures like cavity fillings, dental implants, bridges, dentures, inlays, and onlays and crowns (caps). 

Dental Fillings 

Dental fillings are the most widely practiced restorative procedures. These are done to treat a cavity by removing the decayed portion and filling it. They also prevent any further damage due to the spreading of the decay. The durability of a dental filling depends on the type used: 

• Amalgam Fillings:
  Amalgam fillings are traditional fillings made with a mixture of metals. These are the most durable kind and last for at least 15 years before a replacement is required. They are generally provided on the posterior teeth (Back teeth) due to their non-aesthetic property.

• Composite Fillings:
  Composite fillings are made with a mixture of fine glass and plastic particles. These are tooth colored fillings customized to match the color of the patients’ enamel, which makes them almost indistinguishable from actual intact teeth. Composite fillings hold durability of 10-12 years before needing a replacement. This type of restorations are advised on anterior teeth due to their aesthetic property which provides a natural look.

Crowns 

Crowns are custom-made tooth-shaped caps placed over damaged, decayed, or cracked teeth to restore their proper size, shape, appearance, and strength. They are majorly used to protect treated teeth after root canal or other major procedures. Crowns are also made with different materials that determine their durability. Depending on the type and usage, these may last from 5-15 years. 

Bridges 

Bridges are used to ‘bridge’ the gap between two teeth or to compensate for a missing tooth. A dental bridge is a false tooth placed inside the oral cavity where a tooth is missing. Crowns on the adjacent teeth hold this bridge together to recover the gap in between, regain normal chewing, and a smile that is not crooked. These are also made of varying materials, including gold. However, porcelain bridges are widely used because of their cost-effectiveness as well as teeth enamel-like color. 

Veneers 

A Veneer is a thin, semi-transparent porcelain material that is placed over a tooth to enhance its appearance. This restorative procedure is pursued in instances when a tooth is broken, chipped, discolored, crooked, or misshapen. Instead of complex and expensive procedures like braces, veneers prove to be effective in enhancing smiles. 

Implants 

A dental implant is another alternative to a missing tooth. It is a metal screw placed into the jaw that replaces the root of an absent tooth. It is then covered with a tooth colored crown and does not require fixtures on adjacent teeth to hold it together. Implants are the preferred choice as they preserve the jaw structure by preventing misshaped facial features. 

Composite Bonding 

Composite bonding is a modern and useful technique to restore chipped or broken teeth to elevate tooth structure or to aesthetically enhance the look of a patient’s smile. The procedure involves a composite material that is chemically bonded to an existing tooth. In composite bonding, little to no intact teeth are removed. 

Dentures 

Dentures are an effective way to restore a healthy smile if the patient has damaged gums, broken teeth, or speaking difficulties. It is in the form of a removable plate that holds artificial teeth to make chewing and eating more comfortable.

Root Canals 

Root Canals are undertaken when a tooth becomes decayed to an extent that a dental filling would not suffice as a long term solution. In a root canal procedure, cleaning of the affected tooth is done to the very root to prevent further spreading of the decay and painful toothaches. A root canal is then followed by an onlay, inlay, and a dental crown, respectively.

Waiving a patient’s financial dues could be a practice booster to attract new patients. Typically, this  means a violation of the contract when not collecting the co-payment and could be illegal based on  federal and state laws. However, the Question which often comes to mind is that : what if a neighboring dental office provides dental treatment without collecting deductible or  co-payment? What if the patient is a staff or  relative, friend of a dentist, or a low-income patient needing treatment. Unfortunately, writing-off co-payment can put the dentist on shaky ground and even put the license of the  practice in danger. If a dental  plan issues an invoice to the patient for the cost of rendered treatment, then the collection is a must.  

According to the ADA's Code of Ethics, dentists who waive copayments from a patient and accept  payment by the insurer in full without revealing to the insurer that the patient's portion of the cost is  not being collected are overbilling or committing insurance fraud. This is a breach of the contractual  agreement.  

Why do dental plans need co-payments? 

It is important to note here that the dental plan premium depends upon the cost of the treatments.  If the plan integrates some form of copay and the practitioner never intends to collect, then it changes the entire fee structure of the dental benefit plan. Initially, the dental plan will ask the  practitioner to collect co-payment from enrollee’s patients. However, deception and misrepresentation of  not collecting co-payments could result in unwanted audits and financial stress.  

Is forgiving  co-payment a fraud? 

The issue here is not a matter of being sympathetic or kind to the patient's plight. Some would argue  long-time loyal patients deserve a discount, and even if you wish to provide, apply discounts both to the plan's  portion and the patient's copayment to avoid getting ripped off. 

For instance, if the provider’s charge for a particular service is $400, with $200 paid by the insurer and  the other $200 is the patient’s co-payment: and you have decided to waive off copayment as a  regular business practice, then you should offer a discount to both the parties . The non disclosure of such unlawful practice to the insurer risks possible allegations. 

Here are the following options concerning discounting co-payments without question: 

1. The practice of no discount/waive co-payments. 
2. To stay within the boundaries of law and provide discounts, a provider should consider offering the same extent to the insurer and the patient. Thus, a 25% discount on the insurance  payment amount as well as the co-payment can be a good option. 
3. The next safest course for the provider is to notify the insurer about the discounted co-payments to a particular patient for a specific claim. Send a letter to the payor for the claim  form. Also, do not forget to offer a similar discount to the payor for any breach. 
4. Every state's laws related to discounting co-payments are different. Some states  specifically state that collection of co-payment is a must, irrespective of in-network  charge. 

Reasonable efforts to avoid overbilling and collecting co-payments 

• Offer easy payment plan: Offering different payment options such as credit/debit card, online  payment portal, and auto-pay on specific dates help co-payments. 
• Send billing statements: Utilize the resource at your disposal to send billing statements and monthly reminders of the  balance amount.
• Keep up with collections: If you are struggling with financial stability, it might be time to consider  outsourcing professionals for the uncollectible amount. 
• Follow the rules: Disconnect with patients who insist on writing off/ not collecting co-payments  and are not willing to pay his/her portion. 

Pre-authorization and pre-determination can create confusion for even the savviest of professionals. Is  there a difference between them? Digging a little deeper into both can benefit any practice in filing dental claims without  any difficulty to remain profitable. For your daily financial management, ensure that you understand  the importance of pre-authorization & pre-determination. 

What is Pre-authorization? 

Pre-authorization is a process that requires written advance approval for the rendered service. In the  realm of insurance, it comes into the picture when the patient is unsure about their insurance plan &  its coverage and fails to obtain the necessary reasons in the case of denied payment. The validity for pre-authorization is 60 days. Typically, by submitting a pre-authorization treatment claim, you are saving yourself and your patient from the trouble of rejected claims and unexpected co-pays & deductibles. 

In essence, pre authorization also includes other additional elements like radiographs, diagnostic notes, x-rays, narratives, procedure codes, periodontal charting, etc., to ensure if those services are medically  necessary. Treatments such as root planning, scaling, etc., require pre-authorization to determine the  patient's payment portion. In the world of dental billing, pre-authorization helps establish trust and  helps protect your office’s income. Furthermore, it also depends on the policy plan and state laws. 

Some plans recommend obtaining pre-authorization, such as Medicaid, Medicare and managed care  plans. However, if the beneficiary exhausts the annual maximum limit, leaves the insurance plan  before the treatment, or duplicates a claim for the same treatment from a different dentist, the claim for that plan can be rejected and the can be downgraded as well. 

What is Pre-determination? 

Pre-determination is also known as pretreatment estimate or pre-estimate of benefits. Therefore,  ultimately, it is a way to view individual plan specifics and see the transparency of cost. It is a  formal inquiry of a patient's coverage and eligibility and at the same time does not give a guarantee of reimbursement. Unlike  pre-authorizations, pre-determinations are a trade-off for dentists with patients thinking that the dentist's cost is more painful than the treatment. Every individual's financial situation is different. Hence pre-determination can provide a written estimate for the desired treatment. Pre-determination caveats leave time for patients to forget or reconsider the  rendered treatment. In addition to estimating the out-of-pocket expense, pre-determination helps assert that the beneficiary is indeed a covered enrollee in the plan. 

Many insurance companies do not consider pre-determination as a promise to cover the cost of care  especially in the case of discrepancies. It is used to support the documentation such as exclusions, limitations,  enrollee eligibility on the treatment date, and coordination of benefits before providing any  treatment or else these things become solely the patient's responsibility. A significant downside on pretreatment estimates is that  the patient will go untreated, hampering your dental practice’s income. On one hand, it is a  helpful financial tool when it comes to estimation. On the other hand, stopping the cash flow for obtaining pre-determination from the insurer can often take upto two to six weeks.  

Using Pre-determination a breakthrough in your practice 

The world of dental billing is volatile yet profitable if handled appropriately. Here are a few ways to  avoid guesswork in financing. 

Educating Patients: 

Train your staff to educate patients about their plan and how costly procedures such as crowns can  fit into their wallets along with dental care. Through information literacy, your office can have a steady acceptance rate for the treatment plan. By educating them, you will gain their trust when  they are ready to schedule an appointment. 

Scheduling: 

Practitioners juggle between recare and operative visit thinking how to schedule for  profitably. Firstly, consider recare appointment and then the operative one after a few weeks as you will still have the time for pre-determination. Secondly, wait to schedule the operative visit until  authorization as it can help patients get immediate care. 

For same-day treatment: 

For the same-day treatment, you can receive pre-determination on the phone. Though not  recommended, as written one is a more accurate confirmation that you can get on the insurer's website.  This means that the patient knows approximate prices of what he/she is responsible for and what the  insurer will pay.