Managing Orthodontic Insurance
Creating a Seamless Experience for Clinician and Patient
THE NEXT DDS
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
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.
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?
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
- Automatic monthly
payments authorization form (if needed)
Once the agreed-upon payment
is submitted, it is permissible to proceed with record taking for orthodontic
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
- Type of transaction
- Primary payer and
- 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