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QUESTION: My question has to do with coordination of benefits. Let’s say our patient has two insurance coverages, and neither know about the other, thus making both policies reflect as primary. It is the patient’s responsibility to let each insurance company know about the other plan, correct? As far as how to handle these, I have had some policies that should be secondary tell me that sending the primary’s explanation of benefits (EOB) along with the claim will suffice, while others tell me that they absolutely must have the primary’s information on file before we can file a claim or they will automatically deny it (even when we send the EOB from the primary). If both show as primary, are we required to file both?
A lot of our troubles arise from divorce situations. We know the divorce decree dictates, but we’ve had some cases where the insurance companies do not know about each other and the parents are not on speaking terms, thus putting our office directly in the middle. How are we supposed to handle these situations? Thank you for your help and insight!
ANSWER FROM PATTI DIGANGI, coauthor of the “DentalCodeology," series of books:
If your patients are fortunate enough to be covered by two dental plans, it does not mean—even if the patients believe it does—that benefits are doubled. There is not one single answer as to who is responsible for notification of two dental plans. Though patients don’t realize this, it can take considerable time and effort on the part of your staff to file claims. It is the cost of doing business.
When you’re dealing with divorce situations, the way to handle them is very carefully. Make sure you are on sound ground with your information. Even if the carriers don’t know about the two policies, your office does. Even if it were the responsibility of the patient or policy holder to notify your office, the dental practice knows that policies contain a coordination of benefits (COB) clause. Filing both as primary is inviting an extra burden.
COB is the method for determining how benefits will be paid for patients who are covered by more than one insurance plan. It ensures that no more than 100% of the charges for services are paid. Plans will coordinate the benefits to eliminate over-insurance or duplication of benefits. For your information, the ADA provides a Guide to COB and other training information.
Many factors determine how COB is handled, including state laws, processing policies of the carriers, contract laws, fully insured versus self-funded plans, and types of COB used. Your state rules for COB are available online on page 9 of the link. In general, rules determine which is the primary dental plan for children whose parents are divorced, separated, or not living together. If rules do not determine which plan is primary, coverage will be shared equally between plans. These rules are superseded by a court order that establishes the person responsible for the child’s coverage.
As far as the expectations and requirements of individual carriers and their policies, in general, sending the EOB should suffice. If a carrier has different requirements and bounces back your submission, unfortunately you will need to take some time to contact them.
There is no doubt that dental benefits can help our patients. At the same time, it adds to the cost of doing business in your office. Do your fees include this? Often fees are simply arbitrarily set.
Now that we’re at the end of the year and end of the decade, it’s time for a review. The single most important driver of profit is charging the right fees for the services delivered, and that fee structure includes staff time.
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