Dental Assistant Instruction Pack 4 PDF

Dental Assistant Instruction Pack 4 Lessons 22-26 0204551LB04B-74 Dental Assistant Instruction Pack 4 Lesson 22—Dental Insurance Lesson 23—Radiology Part 1 Lesson 24—Radiology Part 2 Lesson 25—Impressions Lesson 26—Restorative Dental Procedures No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, for any purpose, without the express written permission of U.S. Career Institute. Copyright © 2009-2024, U.S. Career Institute. All Rights Reserved. 0204551LB04B-74 Acknowledgments Margaret Graham, M.Ed., Author Sheila D. McCray, M.S., CCS, CCS-P, Author Martha Roden, B.S., Author Celeste Yeik, AAS, Subject Matter Expert Editorial Staff Janet Perry, B.A., Vice President of Academics and Compliance Brenda Blomberg, B.A., CPC, Curriculum Department Manager Christopher Pimental, B.A., Project Manager Julia Bauernfeind, B.S., Editorial Assistant Jane Bullinger, Editorial Assistant Jessica Babb-Raymundo, B.A., Graphic Designer U.S. Career Institute Fort Collins, CO 80525 www.uscareerinstitute.edu Biographies Margaret Graham, M.Ed. Margaret Graham is an experienced educational writer and editor with more than 30 years of experience. Sheila D. McCray, M.S., CCS, CCS-P Sheila McCray is an experienced instructional designer, writer and medical coder. Sheila earned her master’s degree Instructional and Performance Technology from Boise State and a bachelor’s in Journalism from Temple University. Martha Roden, B.S. With a bachelor’s degree in Nutrition and Natural Resources, Martha Roden started her career as a nutritionist, explaining vitamins, nutrition and diet to her clients. A chance conversation with a client led her to a job as an engineering assistant and a technical writer. Next, she moved into technical training to get firsthand feedback from people regarding her explanation skills. However, teaching people to use software made her realize how difficult it was to use, so Martha moved into the usability profession—helping design software that was intuitive and easy-to-use. She’s definitely had a dynamic career, but everything she’s done has focused on helping people “find what they need and understand what they read.” Celeste Yeik, AAS Celeste graduated from Laramie County Community College in 2006 with her AAS degree in Dental Hygiene. She serves as the SME of dental assisting with U.S. Career Institute. Celeste also works as a full time clinical hygienist for Peak Dental Services where she acts as a Lead Hygiene Mentor. Celeste resides in Colorado and enjoys spending time outdoors with her husband Dustin and their three daughters. Table of Contents Lesson 22: Dental Insurance Step 1: Learning Objectives............................................................................................................................................. 1 Step 2: Lesson Preview..................................................................................................................................................... 1 Step 3: The Evolution of Dental Insurance................................................................................................................... 2 Step 4: How Dental Insurance Works............................................................................................................................ 2 Dental Insurance................................................................................................................................................ 2 The Insurance Process...................................................................................................................................... 3 The Language of Insurance.............................................................................................................................. 4 Step 5: Types of Dental Insurance Plans........................................................................................................................ 4 Theory Behind Dental Insurance.................................................................................................................... 5 People Involved in the Process......................................................................................................................... 5 How Benefits Are Calculated........................................................................................................................... 6 How Patients Are Covered............................................................................................................................. 10 Step 6: Practice Exercise 22-1....................................................................................................................................... 11 Step 7: Review Practice Exercise 22-1.......................................................................................................................... 15 Step 8: Determine Patient Eligibility and Benefits..................................................................................................... 17 Eligibility........................................................................................................................................................... 17 Benefits.............................................................................................................................................................. 18 Step 9: Practice Exercise 22-2....................................................................................................................................... 22 Step 10: Review Practice Exercise 22-2........................................................................................................................ 25 Step 11: Completing the Insurance Claim.................................................................................................................. 26 Procedure Codes.............................................................................................................................................. 26 Filling Out the Claim Form............................................................................................................................ 28 Tips for Faster Claims Payment..................................................................................................................... 35 Step 12: Practice Exercise 22-3..................................................................................................................................... 36 Step 13: Review Practice Exercise 22-3........................................................................................................................ 37 Step 14: The Life Cycle of a Claim............................................................................................................................... 39 Paper Claims.................................................................................................................................................... 39 Electronic Claims............................................................................................................................................ 39 Superbill or Encounter Form......................................................................................................................... 39 Claims Process................................................................................................................................................. 40 Electronic Claims............................................................................................................................................ 40 Dental Assistant Explanation of Benefits................................................................................................................................... 41 Claims Monitoring.......................................................................................................................................... 42 Step 15: Billing and Collections.................................................................................................................................... 42 Fair Debt Collection Practices Act................................................................................................................ 42 Fair and Accurate Credit Transactions Act.................................................................................................. 43 Equal Credit Opportunity Act....................................................................................................................... 43 Step 16: Legal Aspects of Dental Insurance................................................................................................................ 43 HIPAA Basics: Understanding the Federal Regulations............................................................................ 43 Dental Insurance Fraud.................................................................................................................................. 48 Step 17: Dental Claims Processing from 1 to 10........................................................................................................ 49 Step 18: Practice Exercise 22-4..................................................................................................................................... 49 Step 19: Review Practice Exercise 22-4........................................................................................................................ 52 Step 20: Why This Matters............................................................................................................................................ 53 Step 21: Summary........................................................................................................................................................... 54 Step 22: Journal Entry.................................................................................................................................................... 54 Step 23: Quiz 22.............................................................................................................................................................. 54 Endnotes........................................................................................................................................................... 54 Lesson 23: Radiology Part 1 Step 1: Learning Objectives............................................................................................................................................. 1 Step 2: Lesson Preview..................................................................................................................................................... 1 Step 3: X-rays—What Are They and Where Did They Come From?....................................................................... 2 Advances in X-ray Technology........................................................................................................................ 2 Step 4: Properties of X-rays............................................................................................................................................. 3 X-rays are Electromagnetic.............................................................................................................................. 3 X-rays Travel in Waves...................................................................................................................................... 3 X-rays Are Absorbed......................................................................................................................................... 4 X-rays Ionize Molecules.................................................................................................................................... 4 Step 5: Types of Radiation............................................................................................................................................... 5 Primary Radiation............................................................................................................................................. 5 Secondary Radiation......................................................................................................................................... 5 Scatter Radiation................................................................................................................................................ 5 Leakage Radiation............................................................................................................................................. 5 Step 6: Measuring Radiation........................................................................................................................................... 5 Traditional System............................................................................................................................................. 5 Systeme Internationale...................................................................................................................................... 6 VI 0204551LB04B-74 Table of Contents Doses of Radiation............................................................................................................................................ 6 Step 7: Effects of Radiation............................................................................................................................................. 8 Why Is Radiation Harmful?............................................................................................................................. 8 Specific Damage to Tissues and Organs......................................................................................................... 8 Acute and Chronic Overexposure................................................................................................................... 9 Step 8: Virtual Flashcards.............................................................................................................................................. 10 Step 9: Practice Exercise 23-1....................................................................................................................................... 10 Step 10: Review Practice Exercise 23-1........................................................................................................................ 13 Step 11: Components and Functions of X-ray Equipment....................................................................................... 14 Tube Head......................................................................................................................................................... 14 X-ray Tube........................................................................................................................................................ 14 Position Indicator Device............................................................................................................................... 15 Extension Arm................................................................................................................................................. 16 Control Panel................................................................................................................................................... 16 Clean, Operate and Maintain the Equipment.............................................................................................. 17 Traditional Imaging—Dental X-ray Film..................................................................................................... 17 Digital Imaging................................................................................................................................................ 19 Direct and Indirect Digital Imaging............................................................................................................. 21 Advantages of Digital Imaging Over the Traditional Method................................................................... 21 Step 12: Practice Exercise 23-2..................................................................................................................................... 22 Step 13: Review Practice Exercise 23-2........................................................................................................................ 23 Step 14: How Do I Produce a Diagnostic-quality Radiograph?............................................................................... 24 Characteristics of Radiographs...................................................................................................................... 24 Common Errors in Radiology....................................................................................................................... 25 Step 15: Safety Guidelines When Working with X-rays............................................................................................ 29 Radiation Safety Equipment........................................................................................................................... 29 Step 16: Virtual Flashcard............................................................................................................................................. 32 Step 17: Practice Exercise 23-3..................................................................................................................................... 32 Step 18: Review Practice Exercise 23-3........................................................................................................................ 35 Step 19: Why This Matters............................................................................................................................................ 36 Step 20: Summary........................................................................................................................................................... 37 Step 21: Quiz 23.............................................................................................................................................................. 37 Endnotes........................................................................................................................................................... 37 0204551LB04B-74 VII Dental Assistant Lesson 24: Radiology Part 2 Step 1: Learning Objectives............................................................................................................................................. 1 Step 2: Lesson Preview..................................................................................................................................................... 1 Step 3: Types of Intraoral Radiographs.......................................................................................................................... 2 Bite-wing X-rays................................................................................................................................................ 2 Periapical X-rays................................................................................................................................................ 3 Occlusal X-rays.................................................................................................................................................. 4 Full-mouth Series.............................................................................................................................................. 4 Step 4: Correct Patient Positioning for Intraoral Radiographs.................................................................................. 4 Steps to Prepare and Position the Patient....................................................................................................... 5 Step 5: Positioning the PID for Intraoral Radiographs............................................................................................... 5 Angulation.......................................................................................................................................................... 5 Step 6: Film and Accessories for Intraoral Radiographs............................................................................................. 6 Type of X-ray Affects the Film Size................................................................................................................. 7 Film Holders and Position Rings..................................................................................................................... 7 Step 7: Intraoral Radiographs and Infection Control................................................................................................. 9 Barriers................................................................................................................................................................ 9 The Dental Assistant’s Infection Control 1-2-3 for Radiography............................................................... 9 Step 8: Practice Exercise 24-1....................................................................................................................................... 11 Step 9: Review Practice Exercise 24-1.......................................................................................................................... 12 Step 10: Basic Techniques to Create an Intraoral Radiograph................................................................................. 13 Bisecting Technique........................................................................................................................................ 13 Paralleling Technique...................................................................................................................................... 15 Step 11: Virtual Flashcard............................................................................................................................................. 21 Step 12: Digital Method of Creating the Dental X-ray.............................................................................................. 21 Step 13: Quick Reference Guide for Correcting Technique Errors......................................................................... 22 Step 14: Practice Exercise 24-2..................................................................................................................................... 24 Step 15: Review Practice Exercise 24-2........................................................................................................................ 26 Step 16: The Processing Room..................................................................................................................................... 27 Processing the Exposed Film......................................................................................................................... 28 Processing Solutions........................................................................................................................................ 28 Manual Processing Steps................................................................................................................................ 29 Automatic Film Processing............................................................................................................................ 30 Processing Digital Images............................................................................................................................... 32 VIII 0204551LB04B-74 Table of Contents Step 17: Mounting Radiographs................................................................................................................................... 32 Mounting Methods.......................................................................................................................................... 33 Mounting Process............................................................................................................................................ 35 Step 18: Specialized Radiographs................................................................................................................................. 36 Endodontic Radiographs................................................................................................................................ 36 Edentulous Radiographs................................................................................................................................. 37 Panoramic Radiographs.................................................................................................................................. 37 Common Extraoral X-ray Errors and How to Avoid Them...................................................................... 40 Step 19: Virtual Flashcard............................................................................................................................................. 41 Step 20: Practice Exercise 24-3..................................................................................................................................... 42 Step 21: Review Practice Exercise 24-3........................................................................................................................ 43 Step 22: Why This Matters............................................................................................................................................ 46 Step 23: Summary........................................................................................................................................................... 46 Step 24: Journal Entry.................................................................................................................................................... 47 Step 25: Quiz 24.............................................................................................................................................................. 47 Lesson 25: Impressions Step 1: Learning Objectives............................................................................................................................................. 1 Step 2: Lesson Preview..................................................................................................................................................... 1 Step 3: What Are Impressions?....................................................................................................................................... 2 Types of Impressions......................................................................................................................................... 3 Step 4: Impression Trays.................................................................................................................................................. 3 Standard Trays.................................................................................................................................................... 4 Custom Trays..................................................................................................................................................... 6 Characteristics of Quality Impression Trays.................................................................................................. 7 Step 5: Practice Exercise 25-1......................................................................................................................................... 8 Step 6: Review Practice Exercise 25-1.......................................................................................................................... 11 Step 7: Equipment Used to Make Impressions........................................................................................................... 12 Model Trimmer................................................................................................................................................ 12 Vacuum Former............................................................................................................................................... 13 Vibrator............................................................................................................................................................. 13 Laboratory Handpiece.................................................................................................................................... 13 Sandblaster....................................................................................................................................................... 13 Dental Lathe..................................................................................................................................................... 14 Torch................................................................................................................................................................. 14 0204551LB04B-74 IX Dental Assistant Articulator........................................................................................................................................................ 15 Bowls and Spatulas.......................................................................................................................................... 15 Step 8: Materials Used to Make Impressions.............................................................................................................. 15 Alginate............................................................................................................................................................. 15 Elastomerics..................................................................................................................................................... 17 Bite Registration Materials............................................................................................................................. 18 Step 9: Practice Exercise 25-2....................................................................................................................................... 19 Step 10: Review Practice Exercise 25-2........................................................................................................................ 21 Step 11: Safety Precautions When Working with Impressions................................................................................. 22 Step 12: Impressions Procedures.................................................................................................................................. 23 Alginate Impressions....................................................................................................................................... 23 The Automix System for Elastomerics.......................................................................................................... 26 Taking a Bite Registration............................................................................................................................... 27 Step 13: Diagnostic Models........................................................................................................................................... 28 Gypsum............................................................................................................................................................. 29 Making a Diagnostic Model: Step 1 Mix the Gypsum................................................................................ 29 Making a Diagnostic Model: Step 2 Pour the Gypsum.............................................................................. 30 Making a Diagnostic Model: Step 3—Remove the Model from the Impression and Trim................... 32 Making a Diagnostic Model: Step 4 Polish the Model................................................................................ 32 Step 14: Coming Soon: The Future of Dental Impressions....................................................................................... 32 Step 15: Practice Exercise 25-3..................................................................................................................................... 34 Step 16: Review Practice Exercise 25-3........................................................................................................................ 35 Step 17: Why This Matters............................................................................................................................................ 37 Step 18: Summary........................................................................................................................................................... 38 Step 19: Journal Entry.................................................................................................................................................... 38 Step 20: Quiz 25.............................................................................................................................................................. 38 Lesson 26: Restorative Dental Procedures Step 1: Learning Objectives............................................................................................................................................. 1 Step 2: Lesson Preview..................................................................................................................................................... 1 Step 3: What Is Restorative Dentistry?.......................................................................................................................... 2 Step 4: Restorative Materials: Amalgam........................................................................................................................ 3 Contraindications for Placing an Amalgam Restoration............................................................................ 3 Safety Precautions.............................................................................................................................................. 3 Mercury and the Dental Assistant................................................................................................................... 4 Prepare and Apply Amalgam........................................................................................................................... 4 X 0204551LB04B-74 Table of Contents Step 5: Practice Exercise 26-1......................................................................................................................................... 7 Step 6: Review Practice Exercise 26-1............................................................................................................................ 9 Step 7: Restoration Materials: Composites.................................................................................................................. 11 Contraindications for Placing a Composite Restoration............................................................................ 11 Prepare and Place a Composite..................................................................................................................... 11 Explain Aftercare to the Patient..................................................................................................................... 14 Step 8: Restorative Materials—Cements..................................................................................................................... 14 Variables that Affect Cement......................................................................................................................... 14 Zinc-Oxide Eugenol Cement......................................................................................................................... 15 Zinc Phosphate Cement................................................................................................................................. 15 Polycarboxylate Cement................................................................................................................................. 15 Glass Ionomer Cement................................................................................................................................... 15 Composite Resin Cement............................................................................................................................... 16 Step 9: Temporary Restorative Materials..................................................................................................................... 16 Step 10: Practice Exercise 26-2..................................................................................................................................... 17 Step 11: Review Practice Exercise 26-2........................................................................................................................ 19 Step 12: The Dental Assistant’s Role in Restorative Dentistry.................................................................................. 21 The Expanded Functions Dental Assistant.................................................................................................. 22 Step 13: Restorative Procedures.................................................................................................................................... 23 Tooth Preparation............................................................................................................................................ 23 Apply a Matrix System.................................................................................................................................... 24 Veneers.............................................................................................................................................................. 27 Tooth Whitening............................................................................................................................................. 28 Step 14: Practice Exercise 26-3..................................................................................................................................... 30 Step 15: Review Practice Exercise 26-3........................................................................................................................ 33 Step 16: Why This Matters............................................................................................................................................ 34 Step 17: Summary........................................................................................................................................................... 35 Step 18: Journal Entry.................................................................................................................................................... 35 Step 19: Quiz 26.............................................................................................................................................................. 35 Endnotes........................................................................................................................................................... 35 0204551LB04B-74 XI Dental Assistant XII 0204551LB04B-74 Lesson 22 Dental Insurance Step 1: Learning Objectives When you have completed the instruction in this lesson, you will be trained to: Discuss the important of dental insurance to patients and the office. Explain insurance industry terminology. Categorize the types of dental insurance plans. Understand and determine eligibility requirements and benefits. Summarize dental insurance limitations. Complete a dental insurance claim form. Demonstrate how to file insurance claims electronically and on paper. Relate how HIPAA’s Electronic Transaction Standards Rule affects dental insurance. Step 2: Lesson Preview Patients with dental insurance and those without could have different dental experiences. For example, overall cost. Patients with dental insurance often pay less per visit than those without insurance. Lack of insurance might also prohibit them from being able to afford the full treatment they need. Continuing, they might visit less due to costs. For example, instead of regular, preventive visits, they might only see a dentist when they have a problem. Even so, they may be unable to afford more complex procedures. Finally, patients who have insurance also have options. They can often chooses from a wide variety of dentists or offices. ONLINE LEARNING Build on what you’re learning by viewing the article at: https://www.cdc.gov/nchs/data/hus/2019/028-508.pdf. This Online Learning exercise shows interesting statistics. Of particular note are the statistics that shed light on poverty levels and patients’ access to dental services. If you or your spouse and family are lucky enough to have a good dental healthcare plan, you’re probably aware of the amount you save each year in out-of-pocket expenses for dental care. Dental Assistant Do you call and visit your dentist more often, even for minor problems, because you know your insurance carrier will foot the bill? Of course! Most people want to keep their teeth healthy, but not everyone can afford it. People often get dental insurance through an employer, or they purchase an individual policy. As with medical insurance, the dentist often must submit a preauthorization form before he performs an expensive procedure. Then he must file a claim with the insurance company and document the necessity of the procedure before he can get paid. The process isn’t very complicated, but it must be done right to obtain payment. And if you’re an administrative dental assistant, you’ll likely participate in this process. In this lesson, you’ll learn about the importance of dental insurance, dental insurance plans and the terminology used in the industry. You’ll determine eligibility and benefits before you submit claims for your patients. You’ll learn how to complete and file a claim form in several different ways. You’ll also learn how HIPAA’s Electronic Transaction Standards Rule affects dental insurance. Step 3: The Evolution of Dental Insurance Insurance has been around since the 18th century, when King Hammurabi of Babylonia (Iran) developed the Code of Hammurabi. This put into law a system practiced by early Mediterranean sailing merchants. If a merchant received a loan to fund his shipment, he would pay the lender an additional “premium” in exchange for the lender’s guarantee to forgive the loan if the shipment were stolen.1 Since that time, insurance has evolved to protect against monetary loss caused by just about every catastrophe you can think of, including fires, floods, accidents, death, disability, illness and yes, dental problems. Dental insurance originated in the early 1970’s. This gave dental patients a wider range of payment choices, as well as different deductible amounts, premium costs and choice of dentists. However, at the same time, some dentists became concerned that the quality of dental services would suffer if dental insurance companies began to determine diagnosis, treatment and fees for a particular service. Today, their concerns are still valid, as you’ll learn when you look at how dental insurance works. This lesson introduces you to the process and terminology you’ll use when you work with patients and their insurance plans. Step 4: How Dental Insurance Works Dental insurance is important for two reasons. First, it helps patients with the high cost of dental care. Second, it contributes to the dentist’s income. Dental Insurance The terms dental insurance, dental health insurance and dental coverage are the same. Dental insurance reflects a financial assistance plan that helps patients pay for dental treatment. 1. It is a contract between an insurance company, or carrier, and an individual or a group. 2. The individual or group enrolled in the dental insurance plan is called the insured. 22-2 0204551LB04B-22-74 Dental Insurance 3. The contract, or policy, states that in the case of certain preventive care, injuries or conditions, the insurance carrier will pay some or all of the dental bills of the insured. 4. In exchange for this coverage, the insurance carrier collects payments, or premiums from the insured. The insured pays premiums in advance—they are paid monthly, quarterly, semi-annually or annually, depending on the policy terms between the carrier and the insured. 5. When an insurance carrier pays for medical treatment, it pays benefits. It seems like insurance companies pay out a lot of benefits, right? Actually, insurance carriers typically collect premiums from many people, but pay benefits to relatively few. Therefore, insurance companies can provide their services to their subscribers and still make a profit. Every insurance company requires an itemized list of procedures, medications and other materials before they pay benefits. Every dental procedure and medication has its own code, and different insurance companies and plans have their own specific requirements. You’ll learn about all of this later in the lesson. First, let’s look at the insurance process. The Insurance Process To understand your role in the insurance process, let’s walk through a typical insurance-related scenario at the dental office. 1. A new patient arrives. You welcome her to your office, give her the necessary forms to complete and ask if she has dental insurance. If she does, you make a photocopy of her insurance card to keep in the patient record. You also find her insurance information on the patient registration form (insurance company, address, phone number, policy number and group). 2. Next, you explain your office’s policy on how claims are handled. Do you expect full payment at the time of service? If so, your patient must pay you today and file a claim with her insurance carrier. Or do you file the claim for her? In most cases, your office handles the claim for your patient. 3. After the patient completes the forms and you set up her patient record, she begins her treatment. 4. At the end of the treatment, your patient returns to the front desk to check out. If her insurance carrier requires a copay, collect it now. 5. After you give the patient her receipt, she leaves the office. 6. You fill out a claim form based on the procedures performed by the dentist and send the claim to the insurance company in paper or electronic form. 7. You monitor the status of the claim. 8. The dental office receives payment. 0204551LB04B-22-74 22-3 Dental Assistant The Language of Insurance Before you look at the steps in the insurance process in more detail, let’s briefly discuss terminology. Insurance companies use certain rules to process claims. To ensure everyone understands these rules, insurance companies use standardized terms and definitions that tell you how they will process a claim. Consider the example situation. Liz is a dental assistant for Dr. Grant. She is great at making appointments and keeping track of patients. Yesterday, Dr. Grant’s insurance specialist was out sick, and Dr. Grant asked Liz to check on some insurance information. He asked her to compare the explanation of benefits for three different patients and see how much each patient needed to pay. Then he asked if any of the three had not yet made a copayment. Finally, he asked Liz to check the explanation of benefits to see if any of the three patients had met their deductibles. Liz understands English very well, but these questions sounded like another language to her. She dug through some insurance forms but didn’t have a clue about any of the items Dr. Grant requested. Finally, she gave up and asked Dr. Grant to wait until the next day when the claims specialist returned. Imagine you were Liz. Could you ask someone from an insurance company the right questions—and understand the answers? You will—once you learn the terminology that insurance companies use to discuss insurance claims and benefits. As you progress through the rest of this lesson, you are introduced to insurance terminology as you need it. That way, you will receive your insurance vocabulary in “bite-size” chunks that you can easily digest, as opposed to giving you one giant table of every insurance term that exists! Step 5: Types of Dental Insurance Plans As a dental assistant, you need to familiarize yourself with different dental insurance plans. Patients obtain dental insurance individually, through their employer or through their spouse’s employer. Individual coverage is normally more expensive and less comprehensive, meaning it covers fewer services and provides fewer benefits. That’s why patients rarely purchase individual plans, unless they are self-employed and cannot get a group plan. Most patients have a group plan through an employer or a spouse’s employer. This way, they get better benefits at a more affordable cost. However, the plan does not assume the entire cost—patients still pay a portion of the fee. Group plans typically have an open enrollment period during the year when employees select or change their dental insurance plans through their employers. For example, suppose you have a patient who married in February. Her open enrollment period begins in April. During open enrollment she changes her status from single to married and changes her coverage from individual to family. To understand the various types of dental insurance plans, you must be familiar with the factors that affect each type of plan. These factors are: 1. The theory behind dental insurance 2. The people involved in the process 22-4 0204551LB04B-22-74 Dental Insurance 3. How benefits are calculated 4. How patients are covered Let’s look at each of these factors, starting with factor #1, the theory behind dental insurance. Theory Behind Dental Insurance The theory behind dental insurance is called managed care. Managed care provides low-cost or medium- cost healthcare coverage to everyone. The idea is to make health care affordable, efficient and manageable in terms of cost. Unfortunately, the reality is not always the same as the theory. In many cases, managed care has become “managed cost.” Some dentists who enlist in managed care programs must agree to reduce their fees by as much as 20 percent to get patients. This often encourages them to take on too many patients or provide patients with the least expensive treatment that the insurance company will pay for, rather than what the patient actually needs. In some cases, managed care only benefits the insurance companies, not the dentists or patients. Did You Know? It’s common for dental insurance plans to have an annual benefit maximum, which is the maximum amount of money that the insurance company will pay toward your dental care in a given year. This maximum can vary depending on the specific plan and insurance company. Simple research seems to indicate that the annual benefit maximum for dental insurance plans is around $1,000 to $1,500. However, some plans may have higher or lower benefit maximums. Now let’s look at factor #2, the people involved in the process. People Involved in the Process There are a number of terms for the people involved in the dental insurance process. You read about a few of these terms earlier in the lesson. The provider is the person or organization that provides dental services. Dentists are examples of providers. The administrator is the person in the dentist’s office who oversees the administration of dental benefits plans. This person also negotiates and manages contracts with dental service providers. This is the person to talk to if there are any questions about a patient’s insurance policy. The subscriber, or policyholder, is the person who is enrolled with an insurance company, has his name on the policy and carries the dental insurance. The insured is anyone who is covered by an insurance policy. This includes the subscriber, spouse and any dependents (children). For example, Maria Chavez has dental insurance through her company and is the subscriber and insured. Her husband, Rico (spouse) and daughter, Anna (dependent) are also insured, even though they are not subscribers. 0204551LB04B-22-74 22-5 Dental Assistant A group is an employer or union that provides its employees (subscribers) with an insurance plan. The employees’ spouses and dependents are also covered. The insurer is the insurance company that processes and pays claims. The insurer is also called the third party, carrier, underwriter, agent or administrative agent. How Benefits Are Calculated Dentists charge fees for their dental services. The insurance company then pays these fees based on the service provided (fee-for-service) or based on the number of patients seen (capitation fee). Regardless of the method, the insurance company considers these fees to be the allowable charges. It will never pay more than the allowable charge on any procedure. Unfortunately, the allowable charge is often less than the actual amount the dentist charges. Let’s look at each method of calculating benefits, starting with fee-for-service. Important Note Individuals that receive service and procedures (patients) are first party in insurance terms. The dental office or provider of service is second party. The insurance company is the third party. Fee-for-Service There are three types of fee-for-service arrangements: UCR (usual, customary and reasonable), fixed fee and schedule of benefits. 22-6 0204551LB04B-22-74 Dental Insurance Usual, Customary and Reasonable (UCR) Some insurance companies use a three-part criteria to establish a fee structure for payment of dental services. They look at what is usual, customary and reasonable (UCR). The usual fee is the fee a dentist routinely charges for a particular service. The dentist files a list of usual fees with the insurance carrier. These are called pre-filed fees. The customary fee is the fee normally charged by dentists in the same geographic area. Insurance carriers use pre-filed fees from different dentists to determine the average customary fees for services in a certain geographic area. The reasonable fee is one that is justified because the treatment is extensive or complicated. Insurance companies consider these fees when they decide how much to pay. To help you understand UCR, let’s look at an imaginary situation with Mr. Herzfeld. He arrives to Dr. Halper’s dental office in Boston, Massachusetts for enamel shaping. The usual fee is the fee Dr. Halper charges all his patients for enamel shaping. The customary fee is the average fee that most dentists in Boston, Massachusetts charge for enamel shaping. The reasonable fee is the fee Dr. Halper charges Mr. Herzfeld because he was quite anxious and required mild sedation during the procedure. The reasonable fee is the usual or customary fee, plus an additional fee to cover the extra service of the sedation. Once the insurance company determines the UCR fee, it pays a percentage of that fee based on the insurance policy requirements. The dentist bills the patient for the difference between the insurance payment and the remainder of the dentist’s fee. This is called balance billing. The amount the patient pays is called the copayment. Copayment is a form of dental cost sharing in a dental insurance plan that requires the member to pay a fixed dollar amount for each visit to a dentist or for a specific service. This fee is pre-set; it will be specified in your dental insurance policy. It also may be listed on your dental insurance card.2 Schedule of Benefits Not all dental plans pay according to the UCR system. Some use a schedule of benefits, or schedule of allowances, which lists the procedures they cover and the amount they will pay for each procedure. Unlike UCR fees, these amounts don’t relate to the actual amounts the dentist charges. After insurance pays the scheduled amount, the dentist bills the patient for the difference. Fixed Fee Finally, some insurance carriers use a fixed fee schedule, which is a list of established fees for any treatment received by the patient. As with the schedule of benefits, the fees in the fee schedule don’t relate to the actual fees a dentist charges. However, with a fixed fee schedule, the dentist must accept what the insurance company pays. In this case, the dentists cannot bill the patient for the difference. 0204551LB04B-22-74 22-7 Dental Assistant One type of fixed fee plan is Medicaid. Medicaid is a health program for low-income seniors, children, parents and people with disabilities. The program is funded by state and local governments and was created in 1965 under the Social Security Act. Alternative Payment Arrangements In addition to fee-for-service arrangements, there are alternative payment plan arrangements, such as: capitation, closed panel, direct reimbursement, franchise dentistry, individual practice associations, preferred provider organizations and union trust funds. Let’s look at each of these, starting with capitation. Capitation Plans Capitation means that the dentist agrees to provide all or most dental services on a per capita basis. Per capita means the dentist gets a fixed fee for each patient she sees, regardless of the services she provides. For example, your dentist sees 200 patients each year. Of the 200 patients he sees, 150 are enrolled in a specific capitation plan. The insurance carrier pays your dentist a fixed payment several times each year for the 150 patients enrolled in the plan. This is capitation. Because individual plans are so rare, the majority of capitation plans are group plans—such as Health Maintenance Organizations (HMOs) or Dental Maintenance Organizations (DMOs). These are managed care organizations of healthcare providers who contract with an insurer to provide dental care on a capitation basis (fee-per-patient). Patients are not required to pay the difference between what the dentist charges and what insurance pays. As a result, only high-volume practices profit from these plans. Unfortunately, there is a downside to HMOs and DMOs. Patients can only seek treatment by dentists within the HMO or DMO, which greatly restricts their choice of dentists. Additionally, profitability depends on the number of patients seen, which can result in minimized treatment. This means that treatment choices could be limited to the least expensive options. Perhaps dentists would offer fewer or shorter appointments, too. Some dentists also might feel overworked or stressed to try to intake enough patients to show profit. Let’s look at some other alternative payment arrangements. 22-8 0204551LB04B-22-74 Dental Insurance Closed Panel Programs Closed panel programs are contracts between an insurance company and a small group of dentists. Under the contract, these dentists provide care for eligible patients. Closed panel programs are restricted to a small number of dentists in a particular area. If a patient is insured by a closed panel program, she must choose a dentist who is a member of the closed panel; otherwise, she receives little or no benefits. Closed panel is the opposite of open panel, where any dentist can participate, and any subscriber can see any dentist. An Exclusive Provider Organization (EPO) is an example of a closed panel program. It is a network of dentists who contract with an insurance company to provide care at a reduced cost. If a subscriber visits a dentist who is not a member of the EPO, the subscriber is charged a non-discounted fee. A participating dentist is one who is a member of the EPO and a nonparticipating dentist is one who is not. For example, a patient with a severe toothache is a member of an EPO. He is suffering a great deal of pain and needs to find a dentist nearby with an opening today. He looks in the phone book and after several calls, finds one. Because this dentist does not belong to his EPO, the dentist is considered nonparticipating, and the EPO contract will not cover this dentist. Direct Reimbursement Another alternative payment arrangement is direct reimbursement. Direct reimbursement is a plan where the subscriber pays the dentist directly and then the subscriber’s employer reimburses a portion of the payment. Reimbursement is based on the percentage of dollars spent for dental care. The specific amount depends on the benefits structure. For example, suppose a patient pays your dental office $100 for a teeth cleaning. Her employer reimburses $50 of her payment. This is direct reimbursement. Direct reimbursement plans are self-funded. This means no insurance carrier is involved and the subscriber can choose any dentist he wants. These plans involve no discount fees or write-off balances, so dentists like these plans. Unfortunately, few direct reimbursement plans exist. Franchise Dentistry Franchise dentistry means a group of dental offices operate under a common brand name. The name, along with its services and products, are advertised and marketed regionally and nationally. Dentists who want national referrals and need financial and management consulting often find this option appealing. Under the franchise agreement, dentists must follow certain rules and regulations to promote and market services. For example, suppose your dentist is Dr. Wilson. Along with 2,000 other dentists around the country, she markets her business as part of the “Smile with Style” franchise. She advertises the name and markets new dental products under the same name, rather than her own. This is an example of franchise dentistry. In general, franchise dentistry groups provide their own payment plans and financing, but do not necessarily participate in dental insurance plans. 0204551LB04B-22-74 22-9 Dental Assistant Individual Practice Associations An Individual Practice Association (IPA) is a group of dentists or dental societies that provide dental services and form a contract with dental plans to provide their services to subscribers. Dentists in the IPA provide services on a capitation basis and work from their own offices. Their patients may or may not be enrolled in the IPA. Patients who are not covered under the IPA are charged on a fee-for-service basis. Preferred Provider Organizations A Preferred Provider Organization (PPO) is a managed care organization of healthcare providers who contract with an insurer to provide health care at reduced rates to patients insured under the PPO. Dentists in the PPO agree to the reduced rates in exchange for patient referrals from the plan or organization. For example, suppose your dentist is a member of a PPO. He might receive ten patient referrals every three months. In exchange for the steady stream of revenue from the referrals, he offers a discount on preventive dentistry. Other procedures are paid according to a fixed fee. If a patient with a PPO plan visits a dentist who does not participate in the PPO, the plan still pays a portion of benefits, but not as much. For example, let’s say a patient needs a wisdom tooth removed. If she chooses a dentist from a list of participating providers, she pays a discounted fee for her treatment. However, if she chooses a nonparticipating dentist, she pays more for her wisdom tooth extraction. Belonging to a PPO can help dentists attract new patients or retain existing patients. Like the IPA arrangement, patients who are not covered under the PPO are charged on a regular fee-for-service basis, rather than a discounted rate. Union Trust Funds Union trust funds oversee benefit distribution for members of their plans. Unions determine their own fee schedule, which outlines how benefits will be paid for certain services. Depending on the program and the contract itself, benefits may be paid as capitation, fee-for-service or PPO. Now let’s move on to the next factor, how patients are covered. How Patients Are Covered Patients are covered in one of three ways: primary and secondary coverage, accidental coverage and government assistance. Primary and Secondary Coverage Patients may have coverage through more than one insurance carrier. Primary coverage pays expenses first. Secondary coverage pays charges not covered by the primary insurance. People who are married often have primary coverage through their employer’s group plan and secondary coverage through their spouse’s insurance. You’ll learn about how to determine primary and secondary coverage later in the lesson. A note on secondary billing Secondary billing is usually when the claim is sent to the secondary insurance carrier after the primary has paid their portion. Then a patient billing statement is sent to the patient for the remaining balance. The term secondary billing is not used in this portion of the lesson. 22-10 0204551LB04B-22-74 Dental Insurance Accidental Coverage Patients who are accidentally injured are covered in special ways. Coverage depends on how and where the accident occurred, such as at work, in the car or in other situations. Employment Accidents If an accident occurs on the job, the patient is covered by workers’ compensation. Workers’ compensation systems were established to provide partial medical care and income protection to employees who are injured or become ill from their job. These systems also provide employers incentives to reduce work-related injury and illness. A majority of employers buy workers’ compensation insurance coverage through private insurers or state-certified compensation insurance funds.3 In exchange for receiving workers’ compensation, patients give up the right to sue their employer for negligence. Automobile Accidents If injury to the oral cavity results from an auto accident, the claim may be processed through an auto insurance carrier. Make sure you understand the correct procedures for filing the claim before treatment begins. Other Accidents In some situations, medical insurance handles claims rather than dental insurance. For instance, some medical insurance plans cover oral surgery that is needed as the result of an accident. As a dental assistant, make sure you understand the correct procedures for filing these claims before the patient receives treatment. Government Assistance Any program administered by the government (on any level), falls under government assistance. You’ll need to follow state guidelines to file a claim. Check to determine the correct procedure. Insurance companies hold seminars on how to file claims with government assistance programs. You’ve certainly encountered a lot of new terminology in this field. Let’s review what you’ve learned so far about dental plans with a Practice Exercise. Step 6: Practice Exercise 22-1 Select the best answer from the choices provided. 1. Provider a. Person covered by an insurance plan b. Person enrolled in an insurance plan (usually through an employer) c. Insurance company that provides insurance to individuals or groups d. Person who gives dental treatment to a patient 0204551LB04B-22-74 22-11 Dental Assistant 2. Subscriber a. Person covered by an insurance plan b. Person enrolled in an insurance plan (usually through an employer) c. Insurance company that provides insurance to individuals or groups d. Person who gives dental treatment to a patient 3. Insured a. Person covered by an insurance plan b. Person enrolled in an insurance plan (usually through an employer) c. Insurance company that provides insurance to individuals or groups d. Person who gives dental treatment to a patient 4. Carrier a. Person covered by an insurance plan b. Person enrolled in an insurance plan (usually through an employer) c. Insurance company that provides insurance to individuals or groups d. Person who gives dental treatment to a patient 5. Dental insurance is important because _____. a. the government requires individuals to carry it b. it helps people pay for dental care and provides income for dentists c. people cannot receive dental care without it d. it improves individual’s quality of medical care 6. Dr. Metzger’s hygienist performs a prophylaxis. The insurance company then pays the dentist based on the service his RDH provided. This is called _____. a. fee-for-service b. capitation c. direct reimbursement d. UCR 7. Dr. Ruiz performs various procedures throughout the day. The insurance company then pays her based on the number of patients she sees. This is called _____. a. fee-for-service b. capitation c. direct reimbursement d. UCR 22-12 0204551LB04B-22-74 Dental Insurance 8. _____ typically use capitation. a. PPOs b. EPOs c. DMOs and HMOs d. Group plans 9. _____ means the fee normally charged by dentists in the same geographic area. a. Usual b. Customary c. Reasonable d. Allowable 10. _____ means the fee charged most often by a dentist for a particular service. a. Usual b. Customary c. Reasonable d. Allowable 11. _____ means the fee is justified because treatment is extensive or complicated. a. Usual b. Customary c. Reasonable d. Allowable 12. IPA a. A managed care organization of healthcare providers who contract with an insurer to provide dental care on a capitation basis (fee-per-patient), where the patient is not required to pay the difference between what the dentist charges and what insurance pays. b. A group of dentists or dental societies that form a contract with a dental plan to provide services to subscribers on a capitation basis. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a fee-for-service. c. A network of dentists who contract with an insurance company to provide care at a reduced cost. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a non-discounted fee. d. A managed care organization of healthcare providers who contract with an insurer to provide health care at reduced rates to patients in the organization, in exchange for referrals. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a non-discounted fee. 0204551LB04B-22-74 22-13 Dental Assistant 13. PPO a. A managed care organization of healthcare providers who contract with an insurer to provide dental care on a capitation basis (fee-per-patient), where the patient is not required to pay the difference between what the dentist charges and what insurance pays. b. A group of dentists or dental societies that form a contract with a dental plan to provide services to subscribers on a capitation basis. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a fee-for-service. c. A network of dentists who contract with an insurance company to provide care at a reduced cost. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a non-discounted fee. d. A managed care organization of healthcare providers who contract with an insurer to provide health care at reduced rates to patients in the organization, in exchange for referrals. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a non-discounted fee. 14. EPO a. A managed care organization of healthcare providers who contract with an insurer to provide dental care on a capitation basis (fee-per-patient), where the patient is not required to pay the difference between what the dentist charges and what insurance pays. b. A group of dentists or dental societies that form a contract with a dental plan to provide services to subscribers on a capitation basis. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a fee-for-service. c. A network of dentists who contract with an insurance company to provide care at a reduced cost. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a non-discounted fee. d. A managed care organization of healthcare providers who contract with an insurer to provide health care at reduced rates to patients in the organization, in exchange for referrals. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a non-discounted fee. 15. DMO a. A managed care organization of healthcare providers who contract with an insurer to provide dental care on a capitation basis (fee-per-patient), where the patient is not required to pay the difference between what the dentist charges and what insurance pays. b. A group of dentists or dental societies that form a contract with a dental plan to provide services to subscribers on a capitation basis. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a fee-for-service. c. A network of dentists who contract with an insurance company to provide care at a reduced cost. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a non-discounted fee. d. A managed care organization of healthcare providers who contract with an insurer to provide health care at reduced rates to patients in the organization, in exchange for referrals. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a non-discounted fee. 22-14 0204551LB04B-22-74 Dental Insurance Answer as directed. 16. What is a group plan and why do most people choose it instead of an individual plan? In what situation might someone choose an individual plan? 17. Compare and contrast the schedule of benefits and fixed fee methods of determining benefits. 18. What are some downsides of capitation plans, such as HMOs and DMOs? 19. What early concern of dentists about dental insurance companies is a valid concern today? 20. What is a direct reimbursement plan? 21. Franchise dentistry refers to what? 22. What is a child who is covered by a parent’s insurance plan called? 23. An individual covered by an insurance plan must make regular payments called what to remain insured? 24. An insurance carrier uses a set of what type of fees from dentists to help determine UCR fees? 25. If an accident occurs on the job and requires dental services, what type of insurance program would likely cover part of those fees? Step 7: Review Practice Exercise 22-1 Review the answers to the Practice Exercise and use this as a study tool when preparing for your Quiz. 1. Provider d. Person who gives dental treatment to a patient 2. Subscriber b. Person enrolled in an insurance plan (usually through an employer) 3. Insured a. Person covered by an insurance plan 4. Carrier c. Insurance company that provides insurance to individuals or groups 5. Dental insurance is important because b. it helps people pay for dental care and provides income for dentists. 6. Dr. Metzger’s hygienist performs a prophylaxis. The insurance company then pays the dentist based on the service his RDH provided. This is called a. fee-for-service. 7. Dr. Ruiz performs various procedures throughout the day. The insurance company then pays her based on the number of patients she sees. This is called b. capitation. 8. c. DMOs and HMOs typically use capitation. 9. b. Customary means the fee normally charged by dentists in the same geographic area. 0204551LB04B-22-74 22-15 Dental Assistant 10. a. Usual means the fee charged most often by a dentist for a particular service. 11. c. Reasonable means the fee is justified because treatment is extensive or complicated. 12. IPA b. A group of dentists or dental societies that form a contract with a dental plan to provide services to subscribers on a capitation basis. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a fee-for-service. 13. PPO d. A managed care organization of healthcare providers who contract with an insurer to provide health care at reduced rates to patients in the organization, in exchange for referrals. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a non-discounted fee. 14. EPO c. A network of dentists who contract with an insurance company to provide care at a reduced cost. If a subscriber visits a dentist who isn’t a member, the subscriber is charged a non- discounted fee. 15. DMO a. A managed care organization of healthcare providers who contract with an insurer to provide dental care on a capitation basis (fee-per-patient), where the patient is not required to pay the difference between what the dentist charges and what insurance pays. 16. What is a group plan and why do most people choose it instead of an individual plan? In what situation might someone choose an individual plan? A group plan is an insurance plan provided by an employer or spouse’s employer. It is typically less expensive than an individual plan, which is why most people choose a group plan. However, people who are self-employed often choose an individual plan because they have no employer. 17. Compare and contrast the schedule of benefits and fixed fee methods of determining benefits. Both methods use a list of fixed fees that aren’t related to the dentist’s regular fees and are usually much less than the actual dental fees. The schedule of benefits method lets the dentist bill the patient for the difference between the actual dental fee and what insurance pays. However, with the fixed fee method, the dentist must accept whatever insurance pays and cannot bill the patient for the difference. 18. What are some downsides of capitation plans, such as HMOs and DMOs? Patients are limited to visiting dentists within the plan. And because dentists make their money per capita, the dentist needs to provide the least expensive treatment to the largest number of patients. As a result, patients may get less treatment than they need and dentists may not be reimbursed fully for their efforts. 19. What early concern of dentists about dental insurance companies is a valid concern today? Dentists were concerned that the quality of patient care would suffer if dental insurance companies began to determine diagnosis, treatment and fees for service. 20. What is a direct reimbursement plan? It is a self-funded plan where the subscriber must pay the dentist directly. 21. Franchise dentistry refers to what? It refers to a group of dental offices that license a brand name and operate under it. 22-16 0204551LB04B-22-74 Dental Insurance 22. What is a child who is covered by a parent’s insurance plan called? He is a dependent. 23. An individual covered by an insurance plan must make regular payments called what to remain insured? These are called premiums. 24. An insurance carrier uses a set of what type of fees from dentists to help determine UCR fees? It uses pre-filed fees from dentists to help determine UCR fees. 25. If an accident occurs on the job and requires dental services, what type of insurance program would likely cover part of those fees? Workers’ compensation Step 8: Determine Patient Eligibility and Benefits Now that you are familiar with the various types of dental plans, the next step is to learn how to determine eligibility and benefits. As a rule of thumb, follow these steps: 1. Ask the patient for a copy of her insurance card. 2. Make a copy of the card for the patient’s file. 3. Call the number on the back of the card to verify eligibility. 4. Confirm that the patient is currently enrolled in the plan. 5. Verify dental coverage, including deductibles and copays. 6. Clarify any policy limitations or clauses that affect coverage. Now let’s look at eligibility and benefits in more detail, starting with eligibility. Eligibility Eligibility determines whether a patient is covered under a dental benefits plan, and when coverage became effective. Insurance companies dictate when patients become eligible to receive benefits under the plan. If a patient starts a new job, he normally waits for 30 to 60 days before his coverage takes effect. That’s why it’s important to pre-certify a patient to confirm he’s eligible to receive treatment. All it takes is a phone call to the insurance company (the phone number is usually on the back of the patient’s insurance card). For example, your patient started a new job on June 1 and comes in for treatment on June 15. You call her insurance company and learn that under terms of her dental plan, her coverage will not take effect until July 1. Therefore, she will not be eligible to receive benefits until July 1. It’s also important to know the expiration date—when a patient’s coverage terminates. For example, if a patient comes in for maxillofacial surgery on November 1 and his coverage terminated on October 30, his insurance carrier will not pay for the procedure. 0204551LB04B-22-74 22-17 Dental Assistant COBRA If a patient changes jobs, retires or is laid off, she loses coverage within 30 days of the change. When a patient loses her job, she can choose to continue her coverage during the interim under COBRA. COBRA stands for the Consolidated Omnibus Budget Reconciliation Act of 1985. COBRA lets a patient continue medical and dental coverage for 18 months after loss of group coverage—for example, after losing a job. The difference is that she now pays her own premiums. This is why it’s important to verify the patient’s eligibility status. For example, your patient quits her job. She is in danger of losing her benefits. She elects to continue her coverage under COBRA by paying monthly premiums. In this way, she can continue to receive dental treatments in your office after her group coverage terminates. Benefits Benefits are the services an insurance company will cover and the dollar amounts they pay for each service. Assignment of Benefits Once you know a patient is eligible to receive benefits, it’s essential to have the patient sign the Assignment of Benefits form. This form authorizes the insurance carrier to pay the dentist directly. Normally this form is signed at the first visit and kept in the patient’s record. Predetermination of Benefits It’s also important to find out what services a dental plan covers and the amounts paid by the insurance company. Predetermination of benefits refers to finding out this information ahead of time. Predetermination of benefits is valuable because you know what will be paid before you perform the service. It is also valuable if the service exceeds a certain dollar amount. It’s best to submit a plan for dental treatment ahead of time to determine the benefits payable before treatment occurs as well as the amount of copay, deductible (if any) and eligibility. This way, you’ll get a response from the insurance carrier before providing the service. 22-18 0204551LB04B-22-74 Dental Insurance In some cases, you may have to provide documentation with your treatment plan to get preauthorized. For example, the carrier might request x-rays with the proposed treatment plan. If so, you’d use a dual film packet to take the x-rays and send the extra set of x-rays to the insurance carrier. Or you could duplicate the original x-rays and send the duplicates to the insurance carrier. Predeterminations are only estimates of payment, not guarantees of payment. Types of Benefits Benefits deal with both services and payments. A benefit service is the treatment an insurance carrier will cover. The cost of the treatment is often called the reasonable and customary charge. A benefit payment is the portion of the fee paid by the insurance carrier. The payment depends on a number of factors including the deductible, coinsurance, maximum benefit, limitations and exclusions. Deductible—The minimum out-of-pocket cost that the patient must pay before the insurance carrier will provide benefits. This is usually calculated on an annual basis. Some deductibles apply to the individual, while others apply to the family. For example, suppose Rhonda, your patient, receives a restorative treatment for $1,000. Under the terms of her dental plan, Rhonda has an annual family deductible of $500. Her son has already incurred dental costs of $350 this year, which Rhonda paid out-of-pocket. This means she has $150 left to pay on her deductible before the insurance company will pay anything on her $1,000 treatment. Once she has paid $150 for the treatment, the carrier will pay its portion of the remaining $850 charge. Coinsurance—Once the deductible is met, coinsurance allows the insurance carrier to share the cost of covered services with the subscriber, as defined by the insurance plan. Generally, the carrier pays 100 percent of the cost of preventive services (such as exams and prophylaxis), 80 percent of the cost of basic services (such as restorations), and 50 percent of the cost of major services (such as crowns and bridges). For example, your patient, Sanjay, receives an amalgam restoration on the occlusal surface of molar #31. The dentist charges $143 and the insurance carrier pays 80 percent of that, or $114.40. Sanjay will pay the remaining 20 percent of the charge, or $28.60. The insurance carrier may end up paying less than 80 percent of the dentist’s fee, depending on what the carrier considers usual, customary and reasonable. In that situation, the patient will pay more than 20 percent. The carrier may also pay less if the patient is a member of a managed healthcare plan that only pays according to a fee schedule. However, in such situations, the patient’s copay is usually a fixed amount, such as $10 or $20. 0204551LB04B-22-74 22-19 Dental Assistant Maximum Benefit—This is the maximum dollar amount a benefits plan will pay toward dental care costs in a specific period of time (usually one year). Once that amount is reached, the plan will not pay for any other treatment, even if the treatment is a covered service. For example, suppose your patient has had a bad dental year, with restorations, crowns, extractions and a root canal. Her annual $1,000 maximum benefit has already been paid out when she comes in for her routine exam and prophylaxis. In this case, you must inform her that she must pay for the procedure out of pocket, since she reached her maximum benefits for the year. Note: Some plans have a lifetime maximum benefit for procedures such as orthodontia. Limitations—Limits that the insurance carrier puts on the amount of benefits it will pay. Limitations can be based on dual coverage, least-expensive alternative treatment, non-duplication of benefits and pre-existing conditions. Dual coverage means the patient is insured under more than one plan. Each carrier pays a portion of the cost for dental services provided to the same patient. One carrier pays first (primary carrier) and the other pays second (secondary carrier). However, there are limitations as to how much each pays. Dual coverage Dual Coverage: A patient who is married often has coverage through her Marital Status spouse’s insurance carrier as well as her own carrier. In this case, your patient’s carrier is always primary. Her spouse’s carrier is always secondary. So, you’d submit the claim to your patient’s carrier first. After her insurance carrier pays, you’d submit the balance due to her husband’s insurance carrier. Dual Coverage: A patient who is a child may be covered through both parents. Birthday Rule In this case, you need to determine which parent is primary. The parent whose birthday month falls earliest in the calendar year is always billed first. This is called the birthday rule. If both parents were born in the same month, use the day of the month to determine the primary carrier. The birthday rule applies only to parents who are not divorced. Other rules apply to parents who are separated, divorced or are stepparents. Dual Coverage: Both the primary and secondary carriers pay. The total payment Coordination of cannot exceed 100 percent of the charges. Benefits (COB) Assume your patient receives a service that costs $400. His primary carrier pays $350. The secondary carrier will only pay $50. The total payment never exceeds 100 percent of the charge. 22-20 0204551LB04B-22-74 Dental Insurance Least-expensive Alternative Treatment Not only do limitations apply to dual coverage, but they also apply to types of treatment. The Least-Expensive Alternative Treatment (LEAT) means the insurance plan will only pay for the least expensive alternative treatment. Assume you have a patient who comes in to have a missing tooth replaced. The patient can either have a fixed bridge that costs $4,000 or a removable partial denture that costs $1,000. The carrier will pay $1,000 because it covers only the least expensive treatment. Of course, your patient can still get the fixed bridge, but she will have to pay the cost difference of $3,000 out-of-pocket. Non-duplication of Benefits Non-duplication of benefits means that the carrier does not have to pay for services covered by another carrier. Benefits are paid based on the highest allowable rate for the treatment of either plan. Let’s say the treatment fee is $250. The primary carrier allows $175 for this particular treatment. The secondary carrier allows $190 for the same treatment. Under nonduplication of benefits, the primary carrier will pay $175, but the secondary carrier will pay only $15 because the secondary carrier will not approve more than $190 to be paid for that treatment. Patients often become confused about non-duplication of benefits and you may have to explain it several times. If necessary, explain it again after you receive their predetermination results. This way, your patient understands how the insurance company will process payment. Pre-existing Conditions Many insurance plans have a clause that limits coverage for conditions that existed before coverage went into effect. Suppose a new patient comes to your office for treatment of gingivitis. Her coverage became effective on May 15, but the gingivitis was diagnosed and treated by another dentist six months earlier. Under the terms of your patient’s policy, this is a pre-existing condition and the insurance plan will not pay for further treatment. Exclusions Finally, not all dental services and procedures are covered under the terms of the dental benefits plan. As a dental assistant, you need to be aware of this. For example, your patient gets a cosmetic dentistry treatment. A clause in his benefits plan states that the treatment is “not necessary.” Under the terms of the policy, this is an exclusion and the dental carrier will not pay any part of the fee for this service. 0204551LB04B-22-74 22-21 Dental Assistant Step 9: Practice Exercise 22-2 Select the best answer from the choices provided. 1. _____ determines whether a dental benefits plan covers a patient and when coverage becomes effective. a. Precertification b. Authorization c. Preauthorization d. Eligibility 2. The patient must sign the _____ form to authorize the insurance carrier to pay the dentist directly. a. Assignment of Benefits b. direct deposit c. Precertification d. Predetermination of Benefits 3. _____ refers to finding out ahead of time what services a dental plan covers and the amounts the carrier will pay. a. Precertification b. Authorization c. Predetermination d. Eligibility 4. Under _____, a subscriber continues to receive coverage under the benefits plan for 18 months after losing a job. a. COBRA b. the Coordination of Benefits c. a Pref

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