Dental Professionals recommend treatment according to the patient’s need. However, these may not be the case in various scenarios. Patients rely on dental insurance to cover their treatment, which has been recommended by dentists. However, clauses like “Alternate Benefit” can make amends in the dentist’s recommended treatment as well as covered treatments for the patients.
Alternate Benefit Clause:
Alternate Benefit, which is also known as the “Least Expensive Alternate Treatment Clause (LEAT)”, states that when multiple treatment options are available for a patient’s treatment, the dental claim would be viable on the least expensive treatment. Insurance companies evaluate the diagnosis and recommended treatment of the dental professional and approve claims only for treatments that come under LEAT. As per American Dental Association guidelines, insurance companies have to educate the enrollee about the clause, coverage limits, and other protocols about the insurance plan and LEAT. Additionally, the name and qualifications of the person who will be responsible for evaluating the treatment of the dental professional on the behalf of the insurance company have to be shared with the dentists. The basis of the determination of the approved treatment that would be covered by the insurance plan has also to be shared with the dental professionals. If the dentist or the patient decides to go with the expensive treatment, the insurance company will pay the allowable amount under LEAT, and the difference would be charged as an out of pocket cost by the patient.
Intentions behind Alternate Benefit Clause are not dictating the treatment plans but increasing the affordability of the insurance plans. LEAT allows less funding required by the insurance companies, hence allowing more affordable insurance plans to a large number of people.
The treatment that comes under LEAT varies with the dental plan. Major downgrades are applied over composite fillings which are alternate benefitted to amalgams; posterior crowns are alternate benefitted to all-metal crowns, and crowns are alternate benefitted to large fillings. Additionally, under LEAT, insurance companies provide less coverage for expensive treatments such as root canals, crowns, and bridges. Along with LEAT, dental coverage also depends upon annual maximums and lifetime maximums.
Predetermination of benefits:
Prior to the treatment, insurance companies require predetermination of benefits, which includes recommended treatment, the basis of recommendation, an x-ray of the patient, and treatment codes. This documentation is then evaluated by the insurance companies and provides treatment alternates as well as reimbursement eligibility details.
Insurance Eligibility Verification:
The important step to ensure accurate submission of predetermination of benefits is Insurance Eligibility Verification. Accurate submission of supporting documents and codes are necessary to claim approval by the dental insurance companies. However, a multitude of dental insurance
companies and their protocols requires experts to deal with such procedures. The person dealing with insurance eligibility needs to be well versed with the alternate benefit clause of each insurance company along with the dental industry and various treatment codes. Submitting predetermination of benefits requires prolific knowledge as well as dedicated time to achieve accuracy. Any error or mistake insurance eligibility verification process can lead to claim denials, treatment downgrade, payment delays, and faulted RCM process. The person responsible for managing the Insurance Eligibility Verification process needs to deal with co payments, co-insurance, deductibles, patients’ plan eligibility and status, payable benefits, exclusions, insurance coverage detail, treatment codes, etc.
Handling above mentioned tasks can be highly strenuous for a dental professional. Even though hiring an expert can seem a viable option, it could be expensive and riskier than outsourcing similar services from a dental billing company. A hired employee will be the responsibility of the dental professional, and the process will still be prone to errors and mistakes. On the other hand, outsourcing such services can be highly beneficial. Dental billing companies are highly trained experts who possess profound knowledge of their domains. Each process is separately handled by such experts and documentation is passed through various channels that ensure high accuracy. Additionally, any committed error is the responsibility of the company rather than the dental professional. Considering all of these benefits, 90% of the American dental professionals are outsourcing these services from companies like Capline Dental. With years of experience in handling such processes, Capline Dental Services has won the trust of thousands of dental professionals by providing eminent services with the best track record of claim approvals.