Thursday, February 17, 2005

Understanding Insurance Benefits for Dental Exams

Most offices are aware of patient initial and recall exam frequencies that are found in different insurance contracts and their differences; i.e. two exams per year vs. two exams per year with a frequency limitation of one every six months.

What most offices do not know is that some insurance companies do not distinguish between the types of exams for which they provide benefits.

They will pay for only a certain number, usually two, of any type of exam. And although the benefit levels may vary for eligibility, a time consuming initial and emergency exam is, frequency-wise, equal to a usually routine recall exam.

Therefore, it is important to understand the requirements of an exam as defined by an insurance company and the needs of your patient so that their visits can be planned to maximize their covered benefits.

For example, you perform an emergency exam on a new patient that requires you to place a sedative temporary. A claim is then filed and you receive benefits for both services. This person returns a week later for a new patient comprehensive exam and associated services. A claim is filed for that visit also.

In certain instances, you may find that the less expensive emergency exam satisfied the patient's contractual frequency which will not entitle you to receive the benefits for the more expensive comprehensive exam. Although the patient can be billed directly for the service, they have potentially lost benefits if they don't reach their yearly maximum.

Therefore, proper planning of patient care and their visits is important, especially if specialties are involved. If you refer an emergency patient out to a specialist for, say, endodontics or periodontics, unfortunately it is often the first one to file a claim that receives the exam’s benefits.

To avoid this, clearly understand your patient's plan. This will allow you determine how to file a claim and for what visit frequency may be important.

File your claims for the more comprehensive services first and make the patient aware that they will be responsible for the less expensive visits.

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