When Do You Need Predetermination Vs Preauthorization

Predetermination and preauthorization in dentistry are both processes followed by the dental team in a practice that deals with the verification of insurance coverage and treatment costs for a patient before undertaking the recommended services and procedures.

Predetermination implies that dental practices provide the relevant details of a suggested dental procedure to the insurance organization before the commencement of treatment. This step helps the dental team comprehend the coverage amount as well as the financial liability of the patient.

Preauthorization, however, is mandated by the insurance company before any patient receives any suggested treatment or medication.

The need to differentiate predetermination vs. preauthorization in dentistry

These requests are made by the dental team based on any scenario with a patient. One is essential to ensure that the insurance company provides coverage for the treatment, while the other is an approximate cost estimate.
The dental team needs to understand that any estimate offered by the insurance company to the practice does not guarantee any payment by it to the practice.

A predetermination helps the dental team get an estimate of how much coverage the patient will get for the procedure. As this is just an estimation, it might not include any limitations or exclusions.
The team needs to note that if the eligibility of the patient has changed before the commencement of service, the coverage for the procedure can be rejected even if predetermination was done. Such a step helps to prevent claim denials and manage patient expectations when it comes to liabilities that need to be covered by the patient, such as out-of-pocket expenses.

A preauthorization or prior authorization is based on the contract with the insurance company and is generally a requisite when it comes to surgeries, including Medicaid providers.

When are predetermination and preauthorization needed by the dental team?

To understand such a requirement, one needs to understand the specifics of predetermination and preauthorization, as well as their differences.

Understanding Predetermination

Insurance predetermination is about an insurance company reviewing a proposed dental procedure or treatment before it is provided to the patient. This step precedes preauthorization as it aids the dental team in confirming if the recommended treatment can be covered by the patient’s insurance policy. Some important tips about predetermination:

• The dental practice needs to submit all the relevant documents. This includes the history, suggested treatments or procedures, and applicable codes.
• Approval indicates coverage, subsequent insurance payment, and the patient’s financial responsibility. This is not a final guarantee, however.

Why predetermination is important

• Lowering claim denials: By confirming insurance coverage in advance, the dental team can reduce the possibility of claim denials or partial payments that arise due to insufficient documentation or a lack of consent.
• Greater patient satisfaction: Predetermination helps to improve transparency and helps to manage patient concerns about possible costs. This creates a great deal of confidence and satisfaction.
• Boosting the RCM cycle: Approval in advance offers clarity to the practice and patient and aids in preventing delays in payments and claim denials. Thus, the dental team can ensure faster reimbursement and smoother cash flows.
• Intimation of financial outlay: Keeping a patient aware of policy coverage details and visibility of all potential payments to be made by them will result in informed decisions and increased confidence.

Understanding Preauthorization

Preauthorization or prior preauthorization is a prerequisite made by an insurance company to ascertain the eligibility of certain procedures for patients. It evaluates the necessity for a service or procedure to be administered to the patient. A few treatments and procedures that could need preauthorization include the following:

• Expensive medications and treatments
• Affordable alternative procedures

The recommended treatment or procedure requested by the dental practice needs to be evaluated to determine if it meets the norms:

• It is necessary from a dental standpoint
• It is a cost-effective recommendation based on the patient’s current situation
• No duplication of treatment or service
• Is covered by the patient’s insurance policy

The request for preauthorization is generally the responsibility of the dental team, especially if the patient is treated by a dental practice that is part of the plan’s network. There can also be cases where a patient requests preauthorization based on the patient’s plan.

The goal of preauthorization is to provide optimal and appropriate care for the patient without any delay in treatment. It must be planned well to avoid slowing the patient's progress.

Predetermination and preauthorization are both valuable processes for dental practices and patients to better recognize the benefits, treatment coverage, and any out-of-pocket expenses that need to be paid by the patient. While they add an element of work at the commencement of the treatment process, it makes better sense in the long run as they help lower claim denials and increase patient confidence in the practice.

The dental practice can also outsource all billing and insurance processes to a specialist like Capline Dental Services, which can handle the predetermination and preauthorization tasks as and when required. They can validate the coverage of recommended procedures so that the dental team can focus on quality care and treatment of patients.