Dental insurance verification plays a significant role in the successful running of a dental practice. It allows dental professionals to provide necessary treatment to the patients, receive maximum allowable reimbursement from the insurance company, and helps them build a positive rapport with patients by avoiding any unexpected bills . This article will talk about how to verify the insurance coverage of your patients and a checklist for dental insurance verification.
What is Dental Insurance?
Dental insurance pays entire or a portion of costs associated with preventive, minor, and some major dental care depending upon the plan type. With dental insurance, the patient can get the necessary treatment without worrying much about the costs. Patients have the option to choose a dental insurance plan as per their requirement as there are several plans available.
Each dental care plan includes three basic services including preventive dental care services, basic dental care services as well as major dental care services. Generally, every dental insurance policy covers most of the preventive services, fewer basic services and the least amount of major services.This is why the kind of dental care service that you are opting for in your plan is crucial as you need one that provides you the best value for your money and at the same time takes care of your oral health.
Patient verification for Insurance Coverage
Dental insurance verification is essential before starting the treatment if the patients wish to use their dental insurance during the billing. You need to make sure that the records of your patients are updated. You can do this by simply collecting the required data for Insurance Verification from the patient and verifying it with various means available before the appointment time. Make sure you ask for this information every time they book an appointment with you as there is a good possibility that patient’s coverage or other details might have been updated in the course of the last and upcoming appointment .
Patient verification could be done with help of one of the following modes.
Follow the steps below to verify your patient’s dental insurance coverage:
Verify Eligibility: You can verify the insurance coverage of your patient with the help of one of the modes mentioned above.. It will allow you to verify if the patient is actually covered under any plan or not.
Patient/Policy Information: Confirming Patient/Policy information is just as important as verifying eligibility, because it doesn’t matter if the patient has any active policy or not if we can’t submit a claim to Insurance after the services are rendered.
Check Coverage,Maximums, Deductible & Service History: Check the insurance plan benefits, Maximums & Deductibles and inform your patients about them so that they know how much their insurance company will pay and how much they are liable for. Collecting service history of the patient is must as a service performed in the past might impact reimbursement of a service in treatment plan.
Keep Patients Apprised of:
Treatment Plan: Patients need to have a clear idea of their plan coverage and limitations. So, it’s your responsibility to make them aware before starting the treatment. It will allow you to get paid on time from the patients and insurance company.
Claim Processing Guidelines: Let your patients know about the claim proceeding guidelines in advance. Simply use an information sheet explaining the claiming process and other instructions and have it signed by the patient.
Checklist for Dental Insurance Verification
Having a dental insurance verification checklist can speed up the process and spare you necessary time which you can utilize in the treatment process. To make it easier, here are the primary things that you must check during dental insurance verification:
Many individuals have more than one healthcare insurance plan as they are covered under an employer-based plan while also being covered via spouse’s plan. Being covered under two health insurances can be a real benefit while submitting claims as it can enhance the coverage amount allowing a person to save more money on their dental insurance costs. When a person has primary and secondary insurance that means primary insurance pays first for medical bills while secondary insurance pays only after the amount paid by primary insurance doesn’t meet the entire cost. Generally, secondary insurance pays for some or all the remaining amount. In such cases, a person finds secondary insurance useful in lowering their dental care payments depending upon how much amount the primary insurance provider provides. In case, if primary insurance denies paying for the dental care claims, then secondary insurance may or may not pay the same or rest of the cost depending upon the coverage plan.
Know about switching between primary and secondary insurance:
It is possible to change between primary and secondary insurance and for that, an individual who wants to stop the coverage of his/her primary insurance just needs to inform their secondary insurance about it. They should also tell their secondary insurance provider that from now on they will use their secondary insurance as the primary one. However, it is advisable to check for some rules to preserve the integrity of information.
Listed below are some of the steps to switch secondary insurance to primary one:
What does Coordination of Benefits mean?
When an individual is covered under two insurance plans and gets health claims payout for both the insurance plans then this process is known as Coordination of Benefits. A general example of coordination of benefits is when someone's partner has a family health insurance plan and they are able to maximize their health care coverage. In simple words, when a person has both primary and secondary insurance plans then, they can avail coordination of benefits. The primary insurance plan needs to pay first for dental care services then the rest amount will be paid by secondary insurance as per the coverage.
Why keep both health insurance plans?
If a person has excess to two health insurance plans then it is the best way to save money spent on health insurance as some amount will be paid by the primary one and the rest will be paid by the secondary one. However, there are certain rules made to avoid some frauds like a person can’t get paid for medical claims that are duplicated for the same injury or disease. Thus, the total amounts will not be paid by both insurances.
What are the conditions in which a person will be covered under both insurance plans?
Check out these examples to know in which conditions the person is covered under both plans:
Any individual who has more than one insurance plan should always discuss it with their insurance providers about the coordination of benefits and how it will benefit them for a better understanding of health insurance coverage. Additionally, every insurance plan provides different benefits so double check in case of kids to decide if the kids are covered under such insurance or not.
This doc is just telling us how billing proceeds if patient’s have dual insurance coverage, It is not mentioned whether the primary or secondary can be switched with each other or not, If yes then what are the conditions and guidelines.
In Non Duplicate clause - If patients have dual coverage, then it is not mandatory to bill the primary first, we can either bill it to primary or secondary one.
According to statistics millions of dental claims have been denied because a patient was not eligible for the treatment already meted out to him/her by the healthcare provider. This usually occurs when the process of dental insurance verification is carried out in an inadequate manner. Insurance carriers have genuine reasons for not paying the claims submitted to them as they operate with a certain set of rules and regulations. This is why it is very important for anyone who does dental insurance verification to have a dental insurance verification checklist be it in house administrative staff or a team of experts a practice has outsourced this task to.
When it comes to dental patient eligibility verification the people who do it successfully have the right knowledge about different types of insurance plans, kind of insurance providers as well as the different guidelines they need to follow to ensure proper compliance.The amount of information one needs to crosscheck for each and every insurance verification can sometimes be quite overwhelming which is why it is important to have a checklist in place. A checklist is the perfect reflection of the abilities of a verification specialist as it helps him/her make sure that each and every detail related to the claim is covered in the verification process.
Here are the essential things that a dental insurance verification checklist should contain:
In addition to this, the person who is carrying out dental insurance verification should always ask for a copy of new insurance information in order to match with the one stored in the insurance carriers database. After that getting in touch with the insurance provider over call or email should also be taken into account as it helps become 100% sure. Some companies like Capline Dental Services use integrated billing systems that can pull up the same data from electronic records thus making the process of verification easier. We also believe in building personal rapport with patients and are quite honest about any missing deductibles or copays required to get hassle free treatment for our patients and smooth reimbursements for the dental practitioner they have received services from. Our experienced staff has spent quite a few years doing the same and the key to their accuracy and success is their strict adherence to dental insurance verification checklist.
It is essential for every dental practice to keep improving the patient experience which consists of satisfaction in terms of the treatment as well as the billing experience of the service received. Most dentists are quite great at the dental treatment services they offer to their patients but only few manage to provide a good enough dental insurance verification experience even when they have hired few people specifically for this role.The reason why most practices fail to carry out tasks related to insurance verification, billing and collection and credentialing is lack of experience as it is a field as vast as dentistry itself which requires years of experience and specific task related knowledge to carry out efficiently.
This is why it is essential to outsource dental insurance verification services to professionals who have been doing it for years. Nonetheless, there still can be issues with companies you have outsourced your dental insurance verification to which is why it is important to know the same and question the companies about these critical questions to get responses which assure you that your business is in safe hands.
Below is a list of common outsourcing issues with Dental Insurance Verification that you should definitely learn and ask about before getting help for your practice :
Flexible Plans
While most outsourcing companies claim that they provide cheaper dental insurance verification than staff hired for the same in-house, it cannot be true for every practice. Especially small ones who have only a few clients which no more than two people in-house can take care of for all administrative tasks related to dental insurance verification. This is why it is essential to choose from a range of flexible and detailed cost plans which take into account previous expenditure incurred on dental insurance verification services and the cost which the practice will have to incur for the future. Most outsourcing insurance companies can give you an exact cost plan which if is less than your existing cost should be your choice. If the company is unable to provide flexible plans then it becomes a big issue as it is not able to cater to a diverse range of clients.
Task efficiency
Dental Insurance Verification involves a series of steps like verifying the insurance plan, cross checking each and every piece of information from correct documentation to deductibles, last date of service as well as types of treatments covered among other steps. When outsourcing dental insurance verification it is important to take into account the total time taken as well as specific time taken for each activity in order to gauge the efficiency of the process as well as calculate how many patients they will be able to cater to without putting their resources under pressure. Moreover, if the company is taking more time than usual for processes then they can be made more efficient and accountable by changing their conduct. Also, if they fail to do so then the practice should look for someone else to resolve these issues.
Round the Clock Availability
For any practice it is important that the company they have outsourced their dental insurance verification to offers round the clock availability. Since most dentists usually treat patients during the day the staff of the company they have outsourced their dental insurance verification to must be available from the start of the day to well in the evening if the dentists have some questions towards the end of the day after they closed their office. Dentists who are able to form a professional bond with a person from the outsourcing company tend not to take their business anywhere else. On the other hand , if the staff is not available daily, does not return important calls as well as takes more time than required for responses it puts the company in the bad books of the dentist.
Data Security and Confidentiality
Data Security and Confidentiality is one of the most important things that every company which provides outsourcing services needs to take care of. This not only establishes a lot of trust between the dental practitioner who has trusted the company to take care of dental insurance verification but builds a good reputation as well of the company which can help them get more clients. On the other hand, if the company indulges in malpractice or tries to use the data for their own benefit or sells it to another practice then it will not be a long time before they lose much of their business.
A dental insurance verification form is a document filled by the dental practitioner or by the company tasked with dental insurance verification on behalf of the practitioner. It is useful for providing insurance information related to the patient to the insurance company so that the insurance company can tell about the coverage options available for the patient. Once it has been received by the insurance carrier it is delivered back to the dental practitioner.
There are many dental practitioners out there who do not know what a dental patent eligibility verification form is and how important it is for them to get paid which we have tried to answer below. Here are the common frequently asked questions pertaining to dental insurance verification forms :
What type of information does one have to provide in dental insurance verification form?
In the patient information section enter the patient’s name, SSN, birthdate, name of the primary insured, ID number, Insurance carrier, group number as well as information related to the insurance company like address and phone number.
How is proof of eligibility for patients established?
The proof of eligibility for patients is established after the insurance verification form comes back as approved from the insurance provider.
Is it okay for dental offices to download dental verification forms online ?
Dental offices who have hired in house staff for filing dental verification forms can sometimes make the error of downloading it from unauthorized sources online. It should only be obtained from the authorized site both online and offline.
What is the best way to fill a dental insurance verification form?
There is a lot of information required to fill out a dental insurance verification form which is why a professional working in this field is the best choice. He/she will be well versed with the type of paperwork as well as frequently used insurance terminology. By outsourcing this cumbersome task to a professional you will not only save time and money but will also provide quicker treatment for the patient.
Does the dental Insurance Verification form contain full benefits of the patient ?
Yes it does contain the full benefits of the patient.
Why is the dental insurance verification form essential ?
Dental insurance verification forms help the dental offices learn if the patient is eligible for the treatment he/she is seeking as well as how the patient will pay for it. A lot of times patients leave it to the dental offices for verifying their eligibility which when not done by the right personnel can increase the payment challenges.
A network is a collection of healthcare organizations and professionals like specialists, doctors, dentists, surgical centers, and hospitals. All of these have a contract with insurance providers, in which they provide services to patients that are covered by their insurance carriers at a certain rate fixed by insurance providers. Any dental care provider is said to be out-of-network if they have not signed a contract with an insurance company for payments at an affordable rate. Some health plans do not pay for out-of-network providers, except if the patient is admitted in an emergency. In simple words, the patient is liable for the full amount charged by their doctor. Some insurance providers pay for out-of-network providers, however, in these cases, patients need to pay out-of-pocket costs higher than in-network costs.1
Which one to choose in between in and Out-of-Network Providers?
In-Network providers are doctors or hospitals that have signed an agreement with your insurance provider, to provide dental care services at a discounted rate. On the other side, out-of-network providers are the ones who have not signed any agreement with your insurance provider. Some insurance providers cover only the services included in the network plan while others cover services in both in and out of network plans.
How much Out-of-Network costs?
A patient is charged with out-of-network costs when their dental care provider has not agreed with costs decided by the insurance provider. It means that your dental care provider may charge you for the full amount of treatment. In such a case, your insurance provider will not pay any amount and the complete burden of payment will fall upon you. It can also result in higher costs charged by the dental care provider associated with out-of-network fees. To avoid such issues, you can educate yourself on plan limitations and additional charges options.
Continue reading this article to become familiar with plans' benefits and limitations and to maximize the benefits of insurance.
If the dentist you choose is out of network then check if the same service is available with the in- network. If yes and if you are comfortable in preferring in-network doctors to lower dental care costs, then it can yield in a cost-saving benefit. Additionally, check for certain providers regularly, and determine if they are in the network. In case if the insurance plan is not fulfilling your healthcare needs, then check for alternative plans available in the enrollment period.
Another way to deal with high costs is to know more about the treating hospital, doctors and other services. One must know more about drug assistance programs, co-pay assistance programs, and disease-specific programs. It is also important to check about the cost of medical procedures by using a cost calculator. As medical costs differ from state to state so by using a cost calculator, a person can check about what the things should cost.
One of the most important things, an individual can do is to “ be choosy". This selective decision making mindset helps in selecting the right healthcare plan and checking if the preferred doctor falls in your network or not. Also, if the doctor asks for other blood tests then check if it is available in in-network or not.
The best way to tackle the high costs of out-of-network costs is to know more about the plans. By making communication with your insurance providers, you will be able to avoid high costs associated with out of network.
How to check if the healthcare provider you are selecting is out of network?
Most of the health insurance providers have directories that have a list of all medical providers who come under in-network. If any healthcare provider is not present on this list then that simply means they are out of network. A person can also call the provider directly and ask them about which provider is in the network and which one is out of the network. Additionally, it is also equally important to check if particular insurance is providing coverage only in-network or also providing in-out-networks.
How to check that a person will get out-of-network reimbursement or not?
An individual needs to pay the complete amount to their therapist initially, but depending upon the selected insurance plan, your insurance provider will decide that they will reimburse a portion of the cost or not. Please note that if your insurance company treats your out-of-network services as in-network, still the federal law does not allow the out-of-network provider to pay for the full amount for the medical services availed by you.
For most dentists, it can be quite a tough decision to choose between patients with dental membership plans and patients with dental insurance. This is because the demands and capacity of each dental office and practitioner is different but at the same time the end goal is the same which is to make profit. This is why it is essential to understand the risks and rewards associated with both.
Most of us are quite familiar with the concept of dental insurance but what is not common knowledge is the fact that dental insurance first came into operation as a workable benefit only in 1954. Over the years different network of dentists like PPO’s and DHMO’s have been introduced to provide the best dental coverage to patients as well as to make it easier for dentists to be reimbursed for the services provided.
Dental Insurance Verification is the process of checking a patient's insurance plan with their insurance carrier before the patient receives treatment. This helps ensure that the treatment which is covered in the plan is only given as there won’t be any surprise out of pocket expenses. At the same time, it also helps patients learn about their effective date, waiting period, deductibles and maximums as well as other crucial information.
Nonetheless, the results of the action have been far from the desired outcomes as dentists are continuously met with incessant requests for writing off more and more differences between the cost of services and the amount that the insurance provider has to pay. At the same time, for expensive treatments patients have had to pay out of their own pockets. This is why only the insurance providers who are providing coverage of maximum benefits at minimum costs are preferred over inhouse dental membership plans.
Inhouse dental membership plans are the plans that dentists offer to their patients directly for a monthly or annual fee.These plans can eliminate the extra cost charged by middlemen representing the dentists thereby bringing more revenue to the dental office. They allow a practice to set their own fees, increase uninsured patient loyalty as well as increase the revenue of the practice by a big margin. .
Moreover, apart from catering to uninsured patients in the area they provide instant access to services without asking the patient to wait while tallying the details with the insurance provider or in their own system if they have outsourced the service to a third party. Patients also get to enjoy transparent pricing for all procedures as well as get first hand assessment of what all treatments should they include in their dental membership plan from the dentist himself.
Nonetheless, the challenge with in house dental membership plans is as and when dentists increase their patient base it can become quite difficult to store information as every patient’s membership plan will be different. At the same time, the practices which are providing their patients an in-house plan need to consult an attorney as each and every state has different laws pertaining to what qualifies as an in-house membership plan and what becomes insurance.
Finally, if dental insurance providers are transparent with dental practitioners and offer maximum coverage at good cost to patients then dentists should go for patients with dental insurance. However, if the practice is not too big and sees many uninsured patients come in for treatment then patients with in-house dental memberships plans seem like the right choice.
Every dental practice sooner or later learns that dental insurance verification is quite critical for successful billing and collection.This is because if there has been any oversight at all during the process of insurance verification on part of the dentists or the third party to which the task has been outsourced to then there is a high possibility of the claim getting denied. Moreover, when a claim gets denied the efficiency of treatments as well as revenue cycle of the practice gets affected adversely.
Dental practitioners who have been on the receiving end of a claim gone wrong understand why it is important to be thorough and up to date with the process and all the latest regulations and codes of practice. Billing experts who have been in the field for long also understand the trickiest bits of the insurance verification as they know how important attention to detail is even if they know the process like the back of their hand.
Below is a list of common issues noticed during dental insurance verification:
Incorrect Information
Whether it is the office administration of the dental practice or the verification experts at the company which is taking care of dental insurance verification for your dental office there are quite a few things they need to check. Incorrect SSN, misspelled name, wrong date of birth among other wrong personal details as well as typos are noticed and corrected by attentive dental insurance verification experts who ensure that all the information in the database of dental offices as well as insurance providers matches perfectly and is correct.
Insurance Status and Patient Eligibility
Believe it or not but one of the common issues noticed during dental insurance verification is patient eligibility and insurance status.There are quite a few instances when the patient gets the treatment from the dentists only for the patient and the dentist to learn later on that the patient was not eligible for treatment or the insurance status was not active. This causes a lot of inconvenience to both the patient and the dentist as they need to coordinate with each other over the collection of payment.
Lost Documentation
Dental insurance verification requires correct examination of all the necessary documentation like patient benefits, pre-certification details, coverage details, co-insurance details, contact details and deductible details which can easily get lost during transfer of physical files or can be skipped while online transfer of documentation from one system to another. Dental insurance verification experts ensure that all the details are verified for smooth and fast billing and collection.
It is the right move to trust experts like Capline Dental Services with dental insurance verification as they resolve all the above mentioned issues for you and ensure that you get immediate treatment and your service provider gets paid on time.
COBRA means Consolidated Omnibus Budget Reconciliation Act. This is health insurance that provides coverage to an individual after their job loss or any other significant event that results in a change in life condition that allows a person to change their existing health insurance policy. Some of the examples of qualifying events are the death of a spouse, adoption of a child, etc. Under this scheme, a person remains covered with their former employer’s health plan even if they are no longer employed. Qualified persons under this scheme need to pay their entire premium for covering up to 102% of their cost to plan.
Who is covered under COBRA?
COBRA offers medical coverage for their employees who have lost their health insurance due to loss of their employment. Usually, COBRA allows them to stay covered under their employer's plan albeit at a higher cost. COBRA also provides healthcare coverage to spouses, and children depending upon that person. This policy only applies to the government or private-sector companies which have more than 20 employees. It does not be offered to those individuals who are already covered by the federal government, churches, or other such organizations.
By following the listed steps, an individual can check if they are eligible for the coverage offered by the COBRA health insurance or not:
To avail benefits of COBRA health insurance, an employee needs to be previously employed and be covered by an active health insurance plan. Additionally, they need to be fired, retired, laid off, or quit at any time of their employment. This insurance also covers family members, who are dependent on the employee for fulfilling their financial needs. The dependent could be the spouse who died or got divorced or legally separated from the employee. If an individual is still confused about the eligibility or how to avail the benefits of COBRA health insurance, they can contact the human resource team of employees.
Some of the events that may make an individual lose their health coverage and in turn get the license to be covered by COBRA include:
Benefits of COBRA Health Insurance Plans:
How does the COBRA health care plan works?
If an individual is qualified for COBRA insurance then, their health plan administrator needs to notify them about applying for this insurance. Afterward, a person has 60 days to sign up for this health insurance. During these days, if the individual takes medical care and does not opt for this insurance, still they can claim it from their insurer. After that, a person gets 45 days after signing up to pay for the first premium. If an individual is disabled then, they may get an 11-month extension of COBRA after this period, the COBRA insurance policy will expire. After the time frame of 11 months, an individual needs to pay the high amount of 150% of the premium.
COBRA health policy is the best option to consider in case of losing your health policy sponsored by your employer. It provides an individual with the same coverage they had during their employment. It means an individual can continue with their health insurance plan even after losing their job.
Choosing a dental insurance plan that suits your pocket and fulfils your dental requirements is not easy. You need to know the different types of dental plans available, their coverage limits, and how much you need to pay out-of-pocket in each plan. In order to reap maximum benefits, you need to know the available dental insurance plans in detail. If dentists and patients both are equally aware of the plans, it will keep them on the same page during treatment in terms of coverage and payment. This article will explain the different types of dental insurance plans and how each plan functions.
Types of Dental Insurance Plans
Here are some of the most common types of dental insurance plans:
1. Dental PPO Plan
Dental Preferred Provider Organization plan or DPPO plan is one of the most common types of dental insurance plans. The plan covers a wide network of dentists making it one of the most popular plans as well. It even allows patients to visit out-of-network dentists and still receive partial coverage for it. A DPPO plan usually comes with an annual deductible. Your plan starts sharing costs once you meet your deductible.
| Pros | Cons |
| You are not required to choose a primary care dentist. | You may need to pay an annual deductible for routine dental services. |
| Cost-effective if you see in-network dentists | Pays less for the services received from out-of-network dentists |
| Most in-network preventive dental care services (cleanings, routine procedures, and X-rays) are completely covered.No COPAY options, So the insurance will cover for most of it. | Comes with an annual maximum that may restrict the amount of coverage in a year |
2. Dental HMO plan
A Dental Health Maintenance Organization plan or popularly known as DHMO plan is another widely known dental insurance plan. It’s quite similar to an HMO health insurance plan. It allows you to visit in-network dentists keeping your costs at a minimum. It usually does not cover out-of-network dentists except for some emergency services.
The plan requires you to choose a primary care dentist from the network that is typically your first point of contact. The in-network dentists offer certain services at reduced or no cost to the plan members.
| Pros | Cons |
| It usually does not have a deductible. | Offers a small network of dentists in comparison to the DPPO plan |
| Usually comes with no annual maximum for covered services | Difficult to find local in-network dentists |
| Preventive dental care is covered completely. | Need referral if you wish to see a specialist |
3. Dental Indemnity plan
If you wish to visit any dentist of your choice and are not worried about the costs, the Dental Indemnity plan is for you! Renowned as a traditional dental plan or Fee-for-service plan, it allows you to see any dentist as there is no pre-defined network of dentists to choose from.
In a dental indemnity plan, an insurance company pays a percentage of the charges based on the procedures performed. The plan does not force you to choose a primary care dentist and you may not need referrals to see specialists or receive emergency dental care.
| Pros | Cons |
| Freedom to visit a dentist of your choice | Comes with an annual deductible and coinsurance |
| Need no referrals to see specialists | Higher out-of-pocket costs if you visit out-of-network dentists |
As a dental indemnity plan usually has an annual deductible and coinsurance, you need to pay out-of-pocket costs until you meet the deductible. Your plan will share costs for covered services, up to what is considered usual, customary, and reasonable (UCR).
4. Dental EPO plan
A Dental Exclusive Provider Organization (DEPO) plan allows you to visit only in-network dentists. Although it doesn’t require you to choose a primary care dentist and you don't need referrals to see specialists, it restricts you from visiting out-of-network dentists. A DEPO plan usually has a deductible and a coinsurance.
5. Dental POS plan
Dental Point of Service (DPOS) plans have features of both DPPO and DHMO plans. It covers both in-network and out-of-network dentists but costs stay lower if you visit dentists within the network. You are required to choose a primary care dentist who helps you with referrals if you need to see a specialist.
There are some other types of dental insurance plans available such as Direct Reimbursement plans, Discount or Referral plans (technically not insurance plans), and Table or Schedule of Allowances Plans.
