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Managing Orthodontic Insurance

Creating a Seamless Experience for Clinician and Patient

 

Dental insurance coverage is a key consideration for many orthodontic patients, and understanding how to maximize coverage benefits is important for the future practitioner. Using a standardized approach enables the clinician to deliver the highest standard of care, ensure practice profitability, and create a seamless treatment experience. Outlined here are a series of considerations an orthodontic provider needs to take before, during, and after the patient has his or her first appointment. 

Prior to Orthodontic Consultation

It’s important to verify a patient’s orthodontic insurance coverage before the first appointment. Both the  clinician and staff will need to know about the patient’s coverage for the orthodontic consultation, treatment, and fee presentation.

When first scheduling the consultation, the receptionist should obtain all pertinent information from the patient, which includes the insurance name and phone number, the patient’s date of birth, name, address and phone number. Also important to obtain are the subscriber’s name, date of birth, relationship to the patient, employer and social security number.

The insurance company is then contacted to permit verification of the patient’s benefits and to obtain the following information from the insurance purveyor (the practice’s receptionist or appointed representative should be sure to have the Doctor’s Provider Identification Number available before calling).

  • Insurance Type: Indemnity, HMO, PPO or EPO and the Plan or Group Number.
  • Waiting Period: When the patient is eligible.
  • Contracted Fee: Maximum total fee the doctor can charge for orthodontic treatment.
  • Deductible: Amount that the patient must pay before the orthodontic benefit becomes available.
  • Standard or Nonduplication of Benefits: How dual coverage is handled.
  • Orthodontic Coverage: If it’s available for subscriber, spouse, and child, and if there is an age limit for orthodontic coverage
  • Billing Schedule: Do claims need to be sent monthly, quarterly, semi-annually, or will the payments be remitted automatically? How often will payments be sent?
  • Lifetime Maximum Coverage: What is the available benefit for orthodontic treatment?
  • Preauthorization: Mandatory or recommended?
  • Remaining Lifetime Benefit: How much of the original benefit is still available?
  • Percentage: What percentage of the orthodontic treatment orthodontic treatment fee would be covered by the insurance company?

 It is important to plan enough time with the patient to take necessary radiographs and impressions (either digitally or conventionally) to begin treatment the same day and read the treatment notes to make sure that the patient is ready to proceed with orthodontic treatment (e.g., all restorations needed prior to orthodontic treatment have been completed). The patient should be encouraged to bring all decision-makers to the consultation appointment.

During The Orthodontic Consultation

The entire staff is responsible for providing a positive orthodontic experience in a warm, professional environment and ensure the success of the consultation appointment. During the initial orthodontic consultation, the clinician is responsible for all care decisions and patient education, and a financial or treatment coordinator is the patient’s advocate, helping him or her make important decisions about treatment options. 

The most important consideration here is the patient examination and presentation of treatment options based on these diagnostic and clinical findings. The financial coordinator takes charge of the financial conversation so that the dentist fills only the clinical specialist role. The financial coordinator determines total treatment fee after reviewing the contracted fee (i.e., the maximum amount that this patient can be charged for orthodontic treatment) and presents to the patient the total treatment fee and the remaining balance after insurance (if any). He or she should explain exactly what the treatment fee will cover, and that the estimated insurance portion is determined by the insurance company, insurance coverage is not a guarantee of payment, and that the patient is responsible for all fees not paid by the insurance company. He or she should formulate and discuss payment arrangements with the patient. 

Once the patient has made the decision to proceed with orthodontic treatment, forms should be completed and signed to reflect a legal agreement, each party’s rights and responsibilities under the agreement, as well as all the risks and limitations of the intended treatment. The following should be completed and signed by the patient--or by the patient’s legally responsible party, if patient is a minor:

  • Truth in Lending Disclosure & Agreement
  • Informed Consent
  • Third-Party Financing Agreement
  • Automatic monthly payments authorization form (if needed)

 Once the agreed-upon payment is submitted, it is permissible to proceed with record taking for orthodontic treatment.

After The Orthodontic Consultation

Follow the requirements of any involved third-party financial institutions for submitting and expediting payment. It may be necessary to fax, mail, and/or e-mail the required information and signatures. All the necessary information should be submitted online, a submission box should be prepared if necessary and shipped. The tracking number and the date of shipment should be recorded.

Review and approval of the digital orthodontic treatment plan are then performed. To ensure orthodontic treatment is initiated and remunerated in a timely manner, practice staff should keep track of the cases ready to have their digital treatment plans reviewed and approved by the clinician. Once the clear orthodontic aligners have been received and delivered to the patient, the insurance claim should be submitted. On the initial insurance claim submission, the following information needs to be included:

  • Type of transaction
  • Primary payer and patient information
  • Record of services provided
  • Procedure date (i.e., date the aligners were inserted), procedure code (i.e., adolescent [D8080], or adult [D8090] dentition), and description.
  • Fee. Be advised that if the treatment fee is adjusted due to a professional, cash or paid in-full courtesy, the amount inserted in “31. Fee” of the ADA claim form should match the adjusted fee.
  • Authorization Signatures
  • Assigning the Benefit. The insurance subscriber must sign to authorize the insurance company to pay any available orthodontic benefits directly to the doctor.
  • Ancillary Claim/Treatment Information
  • Months of Treatment Remaining
  • Billing Doctor or Dental Entity 

By ensuring that all paperwork is signed and submitted in accordance with the insurance company guidelines, high-the orthodontist will be able to provide your patient efficient and prompt treatment while ensuring the practice receives reliable payment.

 

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