A very important component of dental revenue cycle management that is often missed or not always taken with utmost seriousness is dental insurance verification. When the team rushes or forgets to complete an insurance verification check, the practice can be faced with claim denials or delays in cash flow.
If a dental insurance verification checklist is duly maintained and followed up by the dental team, then claims can be prepared accurately. This helps to reduce the possibility of claim rejections and enables the practice to get reimbursed promptly.
Insurance verification is a step that needs to be completed by the team before commencement of treatment or service. It ensures that all the information collated regarding the insurance policy of the patient is correct. This helps in the preparation of precise claims. If the team misses out on such a step, there can be a very strong chance for a claim getting rejected, as well as a disgruntled patient.
A rejected claim leads to an additional burden on the team as it needs to collect the right information, ensure a resubmission is done on time, and follow up for payment. Besides a delay in payments from the insurance company, it affects the revenue of the practice.
The dental eligibility verification process can be tedious and time-consuming when policy coverage of a patient changes due to a change of employment or when a patient with personal coverage decides to change the insurance firm.
A dental practice must ensure that insurance verification is done a couple of days before the patient comes to the practice for treatment. All details must be checked and verified by the team.
By completing the process, the team can submit accurate claims. The team can also guide patients on dues and out-of-pocket expenses that need to be paid by the patient. If the patient has any doubts about policy coverage, the team can highlight key details before the patient receives treatment.
A dental insurance verification checklist that the dental team can refer to for a detailed verification of the patient’s insurance policy is as follows:
The team must check for insurance eligibility every time a patient visits the practice for a procedure or service. This will enable the team to confirm the status of the policy and whether the benefits are live. The team can browse for details on the portal of the insurance company and confirm the necessary details.
While determining the eligibility of the patient, a few steps to follow are as:
i. Verifying the effective date is the first step in confirming the benefits that are eligible for the patient. A new insurance plan taken by the patient might have a waiting period, and the patient might not be able to avail the benefits.
ii. Insurance policies come with clauses and conditions. One of them is a plan maximum. This is the maximum amount of coverage that a patient can avail during the plan period. If the patient’s benefits are reaching the plan maximum, the recommended treatment must be made accordingly.
The patients would have to pay for any incremental amount that exceeds the maximum from their own pockets. Based on the patient’s capacity to pay, such a recommendation can affect the cost estimate.
iii. The team and the patient can evaluate typical coverage percentages for procedures done in the past. This can help in identifying the amount of coverage of the recommended procedure. Generally, coverage percentages that patients can derive from policies are usually 100%, 80%, or 50%, while the remaining amount gets borne by the patient.
iv. Like their insurance maximum and coverage percentages, the patient’s deductible can affect how much they are responsible for paying. Most plans include per-person or per-family deductibles that are set on the first day the plan becomes active.
v. It is important to check if there is a deductible before filing a claim submission. The deductible is an amount that a patient would have to pay for treatment before the insurance firm commences coverage for any treatment.
This can then determine the actual amount that a patient would have to pay for treatment. Depending on the plan and insurance company, a deductible can be per person or per family and is usually set on the first day of the plan becoming active.
vi. It is possible that a patient has exhausted all benefits accrued during the year. In such situations, the practice can lay out the case before the patient and schedule the procedure once the policy has been renewed for the coming year. This would have to depend on the urgency of the procedure. If left without a choice, a patient would have to bear the expense out of pocket.
When the team has completed verification of the patient’s insurance benefits eligibility, it needs to probe the specifics of the plan. This is crucial because many patients do not thoroughly review the terms and conditions associated with the policy and the coverage documents.
Dental plans come with exclusions and clauses and are part of the conditions associated with the patient’s insurance plan. These are clauses that cannot be missed by the team even if the patient misses out or does not understand them. These terms can impact how a patient can receive coverage and all the benefits associated with the plan during the year.
Some clauses or exclusions to be checked during the insurance verification process include:
Frequency is a parameter that can affect coverage. A patient’s policy might restrict the number of times that a patient can get coverage for a specific treatment within the plan period. Some policies might include a maximum of three cleanings annually.
Age limitation is a factor to be considered. A patient who is 26 years or older might not get covered under the insurance plan of the parents. There can also be age limits set for a particular service or procedure. A child covered under the parents' insurance plan can get coverage for fluoride till the age of 16, while orthodontic benefits are applicable till the age of 18.
There can be a replacement clause that specifies non-payment for a defined set of dental procedures. An example can be a filling or a lost retainer within two years from the original placement date. Complex procedures such as a bridge might be eligible for a replacement after five years from the original procedure.
There are cases where a patient loses a tooth before the insurance plan became active. In such cases, the insurance company will not provide cover for replacement of the missing tooth. As an exception, a patient might appeal a refusal of coverage if the employer switched to a new insurance firm.
A plan can come with a waiting period. An insurance plan might prevent a patient who is newly enrolled in a new insurance plan from availing benefits for a defined period. The waiting period could extend from some months to maybe some years. Such a clause is usually applicable when a patient undertakes major or restorative dentistry.
An insurance plan might cover only the least expensive procedure when there are options available. Highlighting a less expensive option to a patient is also a legal requirement.
While verifying eligibility for families, the team must realize that family members covered by a single insurance plan might not accrue identical benefits. This is possible because the expense incurred by any individual for the respective maximums or deductibles can vary.
A set of patients having the same group number are entitled to the same coverage. The team must check for the deductible and the remainder of their maximum amount of the patient as this can vary.
A practice can lose the goodwill of a patient when faced with a bill that is significantly higher than when initially presented. The dental team must prioritize insurance eligibility verification before a patient even steps into the practice. The team can follow a checklist to ensure insurance verification is completed to ensure clean claim submissions and faster reimbursements.
