In most dental practices, dental insurance checks equal approximately 50% of the practice income. Considering this, it is essential that the insurance aspect of the practice be managed and monitored with extreme dedication and accuracy.
This area of the practice needs to be both time and cost efficient. Accepting insurance assignment is a financial courtesy to patients and an asset for the practice when systematically handled. Keeping the process simple, yet effective, for filing and follow-up is critical. Insurance, managed on a daily basis, prevents insurance "overhead," loss of control, and slow cash flow from insurance companies.
Studies confirm that each time a written Pre-Determination of Benefits is submitted for review, there is a 50% chance that the patient will go untreated. Therefore, individual practices must establish a policy that indicates when treatment needs to be submitted to insurance companies prior to services being rendered. This process also involves communicating the practice guidelines effectively to patients about accepting insurance assignment. The patients must understand clearly their estimated financial responsibility, and be asked to sign the financial agreement. Whenever possible, the practice should not submit a written pre-determination. Instead, they should do a verbal eligibility verification and obtain plan benefit information.
Three reasons pre-determination patients go untreated
1. After submission of the claim, the practice may lose track of the claim, as in no follow-up.
2. The insurance company may have misplaced or never received the claim, again, no follow-up.
3. The patient's interest, enthusiasm, perceived need, and/or financial status may diminish in the time it takes for the claim to be processed.
· When the insurance plan requires (not just recommends) a written pre-determination.
· When verbal benefit information cannot be obtained.
· When plan benefits are a "set" or "scheduled” allowance and cannot be determined by UCR percentage.
· If the patient appears to be an expert about his or her coverage and insists on a pre-determination.
· When elective treatment is involved, such as implants and cosmetic procedures, and the patient's decision to have treatment depends on knowing if benefits are available.
To evaluate your insurance processing system, ask the following questions:
1. Is insurance processed daily?
2. Do we retain a master copy of patients’ insurance forms with their portion filled out?
3. Does this copy show the correct mailing address and phone number for filing?
4. Is additional information attached or enclosed when appropriate, such as radiographs, photographs, probe chart, or narrative? This is critical to expediting processing.
5. Do you retain a copy of reference for every claim filed? This eliminates refiling.
6. Do you have a file of insurance narratives for procedures performed frequently that have worked effectively for you?
7. Do you have a filing system for pending claims that is in chronological order by the mouth? Can you access these quickly and easily? Do you have the same filing system for pre-determination pending?
8. Do you follow up on pending claims every 30 days? Is this by phone or mail?
9. Do you have a filing system for retrieving paid claims and explanation of benefits if questions arise?
10. Do you have a file of the most frequently used dental plans to access benefit information quickly and easily?
11. If so, do you have a system for updating and keeping this information current?
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Insurance management is very involved and detailed, regardless of the system used. This important area of the practice should be delegated to a specific person on the business staff. Time must be allocated and prioritized for handling this aspect of the business. If you expect timely payments from insurance, careful insurance management is a must!
Here’s to more productivity, more profitability, and less stress!