Dental insurance is a complex arrangement for a practice and a patient. Many practices depend on insurance verification services to confirm patient eligibility and benefits from their respective insurance organizations. This is an important step as it helps a practice gauge the extent of coverage for services and treatment recommended to a patient.
Verification of benefits that can be availed by a patient is generally done at the time of scheduling an appointment of a patient. Details of which insurance company will offer coverage if more than one policy is active, policy limitations, etc need to be confirmed.
An important consideration that needs attention is when a patient has dual coverage. This means that a patient’s treatment will be covered by two insurance companies, which are deemed to be primary and secondary dental health insurance. A practice can seek support from a dental insurance billing company to navigate billing complexities that arise when patients are covered with dual insurance plans.
Many patients have primary dental insurance that comes through their employer, while a secondary dental insurance plan can be purchased separately. A secondary plan also covers a patient as a dependent.
For any patient to avail of benefits from an insurance plan, the practice needs to depend on the coordination of benefits provision. This is needed when a patient is eligible for benefits from more than a single dental plan.
When the primary plan has provided coverage for services rendered to the patient, any additional coverage will be made through the secondary plan.
Dual dental coverage could be applied differently for different patient profiles. For an adult, the primary insurance plan is the one enrolled through employment. A plan that is covered by the spouse will be deemed a secondary plan. Similarly, a plan that offers coverage through present employment would be termed as primary, while a retiree plan would be secondary.
The dental team needs to ascertain which of the plans is primary or secondary. This also depends on specific plan provisions. Some plans might not offer a provision for secondary coverage.
When the dental team applies the provision of coordination of benefits, one plan would be considered primary and the other as secondary. A claim will not be processed by the secondary plan provider if reimbursement has not been made by the primary plan provider.
Once the primary provider has processed the claim, then the secondary provider would need a copy of the EOB or explanation of benefits from the primary insurer.
When a patient has dual coverage, the two insurance providers ensure that the total amount paid together will not be greater than the total amount the practice had agreed to accept through the primary plan or the total allowed charge. This ensures that duplication of benefits does not happen and that a patient does not gain more than what one is entitled to.
For a patient, the main purpose of having two plans is to increase insurance coverage and enable a patient to enjoy a wider range of dental procedures and services. This can help to lower out-of-pocket expenses for a patient, especially for unplanned or unexpected dental procedures.
While the patient will incur higher costs in terms of paying a premium for both plans, there can be significant long-term savings depending on the oral health and needs of the patient. However, there could be services that are repeatedly covered and this leads to overlapping benefits that may not offer additional value to a patient.
For a practice, coordination of benefits can be a complex process and if not interpreted or applied correctly, can lead to denials and an additional administrative burden. However, the practice will have an opportunity to increase the base of patients as it will become more attractive to patients with dual coverage and would need to utilize all the coverage options.
By mastering COB skills, the dental team can be able to draw more patients and increase potential revenue based on additional benefits that the plans allow. There is a vast pool of patients with secondary insurance plans. A practice will lose a business opportunity by refusing treatment to those with dual plan coverage. The team needs to be trained and equipped to handle patients with multiple coverages.
A dental practice needs to understand and accept patients with primary and secondary dental insurance plans. While understanding the coordination of benefits provision can be a daunting task, it can have significant business potential for the practice. While accepting patients with dual insurance plans, the practice must be able to comprehend the rules of each plan and bill the patient accurately. This will ensure that the practice also receives reimbursement from the insurance organizations promptly.
