Dental Insurance PDF

Dental Insurance Unit 3 PART 1  DENTAL INSURANCE Dental Insurance- is a plan that assists the patient or family with the cost of dental care. ⚫Traditional insurance plan is referred to as the indemnity plan ⚫This type of insurance provides benefits for dental treatment that the covered ind...

Dental Insurance Unit 3 PART 1  DENTAL INSURANCE Dental Insurance- is a plan that assists the patient or family with the cost of dental care. ⚫Traditional insurance plan is referred to as the indemnity plan ⚫This type of insurance provides benefits for dental treatment that the covered individual has received from their dentist ⚫These plans have limitations and co-payment options  3 Parties Involved in Dental Insurance Dental insurance is a cooperative effort among the three parties involved in dental care of a client. ⚫The first party is the client—subscriber or insured person. ⚫Subscriber: carries the dental insurance plan or is a dependent of the subscriber (e.g. Spouse or Child)  3 Parties Involved in Dental Insurance The second party is the provider, or dentist. ⚫The Provider provides the treatment to the patient 3 Parties Involved in Dental Insurance ⚫The third party is insurance company, the carrier. ⚫The Carrier pays the claims and collects the premiums. The financial arrangements and benefits in insurance coverage differ from one plan to another, from company to company, and from program to program. GROUP INSURANCE A particular company may purchase an insurance contract for a group of employees who work at that company A plan administrator who represents the employer will negotiate and design the cost of the specific plan with the insurance carrier. The negotiation includes how much the policy will cost and how much coverage it will provide. SHARED RISK ⚫ To prevent abuse of the insurance contract, clients will have a co-payment. Patient is assuming a portion of the cost. ⚫ Example the client has 80% coverage for basic procedures ⚫ The insurance carrier pay 80% ⚫ and the client pays 20% = 100% This is the co-payment: plan requiring policyholder to pay a specific amount or percentage of each claim. FLEX BENEFITS Employees can choose the coverage from a list of options provided by the employer. Insurance Company/Carrier Plans from insuring companies vary from carrier to carriers Examples: Great West Life, Sun Life, Blue Cross, Green Shield, Liberty Health ,Met Life, Aetna Most plans have a Maximum yearly limit per person per household within a calendar year $1000 per year $2500 per year Some plans pay 100% of the cost, some have co-payments and some have deductibles Maximum benefits largest possible amount of payments permitted during a specified time, such as a calendar or policy year or the life of the policy DEDUCTIBLE dental DEDUCTIBLE Annual deductible based on the calendar year or contract year. Client will have to pay a dollar amount before insurance coverage takes effect. Usually $25-50 ROUTINE/BASIC COVERAGE Services that provide maintenance and preservation ▫ Fluoride ▫ Scaling ▫ Fillings ▫ Root canal ▫ Radiographs ▫ Study casts ▫ Biopsies ▫ Extractions MAJOR RESTORATIVE Services that involve extensive restoration of the teeth Co – payment is very common for these procedures ▫ Crowns ▫ Bridges ▫ Dentures ▫ Implants ▫ Perio surgery ▫ Oral surgery  ORTHODONTICS Services involving the alignment of the jaw and teeth Co – payment is very common for these procedures Not routinely a covered benefit EXAMPLE OF GROUP INSURANCE WITH A SHARED RISK Routine Services – 80% Major Restorative Service -50% Orthodontic Services – 50% Deductible - $25  Assignment of Benefits VS Indemnity Contracts Assignment of benefits— when a dental claim is submitted to an insurance carrier, it is usually paid to the beneficiary (subscriber) in accordance with the plan design selected by the employer. Some insurance carriers may allow the subscriber of the plan to assign the benefit payments directly to the dentist, who is not considered the beneficiary. This is known as assignment of benefits. INDEMNITY CONTRACTS A subscriber or dependent goes to the dentist - the dentist charges a fee – the subscriber pays the dentist and submits the claim form to the insurance company for reimbursement. Claims are paid as benefits are used. “That which is given as compensation for loss or damage” This is highly recommended by the ODA. Birthday rule Used to determine primary insurance policy when two or more policies are involved, as with children of parents who each have a different policy or company. The primary policy is determined by earliest birthday of the two policyholders in the calendar year. If the birth dates are the same, the oldest policy is considered the primary policy holder. Calendar year One year, from January 1st to December 31st.  Carrier insurance company or institution that does the insuring. Group policy insurance policy covering a specific organization or business group. Only members of that group or business may belong to that plan. Companies have a multitude of policies.  Claim ▫ a listing of rendered services, fees charged, and dates of service which is sent to insurer. Coordination of Benefits (COB) or Co-insurance Families with more than one family member with dental insurance can coordinate their insurance benefits for total payment of the cost of the dental services Coordination of Benefits (COB) or Co-insurance plan by different insurance companies where both pay on the claim The primary company makes first payment and any remaining claim balance is sent to the secondary company. Both payments together may not exceed 100 percent payment of fees. Coordination of benefits Primary Carrier is responsible for the first payment of the claim. The primary carrier is always the company to which the client is the subscriber. Secondary Carrier is responsible for the second payment or balance left from the primary carrier. A claim form is required to be clearly marked duplicate as well as a copy of the “explanation of benefits” form from the primary carrier. Who do you send to first? October 7, 1985 September 8, 1981 Who do you send to first? February 20, 1989 April 8, 1988 Coordination of Benefits (COB) or Co-insurance 1. At the time of completion of care, prepare two identical insurance claim forms ( one to the primary carrier and the other to the secondary carrier) 2. Have the primary form signed by the appropriate family member and send it out  Dependent ▫ person who is carried as a member of the policy other than the policy-holder. ▫ May be spouse, child, or elder parent relying upon the policyholder's financial assistance.  Exclusion ▫ dental service or procedure not listed under benefit plan.  Insured ▫ policyholder; one who pays the premiums or makes the contract.  Limitations ▫ service that has a restriction ▫ Example 6 month or 9 month recare Preauthorization/Predetermination request sent to insurance company to determine if specified procedures or treatments will be covered by policy and the amount of payment which will be received; also called predetermination. Usually sent on claim form and marked "Pretreatment Estimate.“ After approval and completion of services, the form is resubmitted as a statement of actual services by the dentist. Provider one who renders professional services. Each provider has an identification number. Example: Dentist or Hygienist  Subscriber ▫ insured person, the policyholder.  STANDARD DENTAL CLAIM FORM Definition: Preprinted or computer form that contains information about the insurer, provider, services and fees to be submitted for benefit payment. PART 1 – DENTIST TO COMPLETE Patient information box, name and address Dentist information box, name, address, unique ID # Assignment of benefits box Dentist use only box Client signature Duplicate Box Office verification box Services procedures table PART 2 – EMPLOYEE / PLAN MEMBER / SUBSCRIBER Client insurance information Should be completed by the client/ subscriber(one who holds insurance) PART 3 –PATIENT INFORMATION Information about the client relationship to the insured Secondary insurance information  PART 4 – POLICY HOLDER / EMPLOYER Should be completed by the employer before the claim is forwarded to the insurance company Employee/employer information TOOTH SURFACES (use the following in Block capital letters) O/I = Occlusal/Incisal M = Mesial D = Distal V/B = Vestibular /Buccal L = Lingual EDI – electronic data interchange Sending Insurance Claims Electronically Insurance information is entered into the client’s family file and can be sent electronically to a primary and secondary insurance carrier. Insurance Fraud It is illegal to misrepresent treatment or inaccurately report fees and duties of service to benefit carriers Canadian Criminal Code punishable by law fines starting at 200.00 and up to 10 years in prison Fraud includes billing for services not provided Insurance Fraud Fraud examples committed by Office/DDS/Staff include: ▫ Billing the carrier for higher fees than the patient is charged ▫ Billing before completion of service ▫ Predating or postdating services on the claim form ▫ Changing dates of service for coverage to match the submission date on the claim form ▫ Improperly listing treatment to fit the limitations of dental coverage Insurance Fraud ▫ Billing for services not rendered(provided) ▫ Claims for extra time (or extra surface) spent in providing a service ▫ Falsify signatures or stamps ▫ Waving co-payments and /or deductible ▫ Submitting a claim form for payment twice Insurance Fraud Fraud examples committed by client include: ▫ Signing as a subscriber without coverage ▫ Signing as a subscriber with a carrier in the name of the spouse-false signature ▫ Cashing cheques addressed to the DDS ▫ Signing for dependent/child without coverage