Insurance Guide For Dental Healthcare Professionals

Insurance Guide For Dental Healthcare Professionals

Dental Benefits Basics What is dental insurance? Unlike traditional insurance, dental benefits are not meant to cover all oral healthcare needs. The dental policy is simply a benefit to off-set a portion of the cost of care. Why is dental insurance important? Dental insurance is the second most popular benefit offered to employees after health insurance. It is important to both patients and the dentists who care for them. Dental insurance encourages patients to obtain needed dental treatment Most dental disease is preventable, and dental benefit plans are structured to encourage patients to obtain regular, routine care Based upon a National Association of Dental Plans survey, respondents with dental benefits and their children are 2.5 times more likely to visit the dentist and receive restorative treatment Preventive care often detects minor problems before they become major and expensive to treat Regular, routine care can help to diagnose the onset of serious disease and potentially avoid complications for other diseases Did you know In 2007, Americans made about 500 million visits to dentists, and an estimated $98.6 billion was spent on dental services. CDC Oral Health Employed adults lose more than 164 million hours of work each year due to dental visits/disease. Surgeon General s Report on Oral Health in America Every $1 spent on preventive dental care saves $8 to $50 in restorative and emergency treatment. American Dental Hygienists Association How do people choose their dental insurance? Most people purchase their dental coverage through an employer. This means the employer, and not the individual, chooses the dental carrier and plan type. Only about 2% of insured people purchase dental insurance directly from a carrier. 2

What are the most common types of dental coverage? Dental preferred provider organization (DPPO) plans These plans utilize a network of participating dentists who have agreed with the dental carrier, to provide covered services at reduced rates instead of their full fees. The dentists compensation is typically comprised of payments from the patient (coinsurance, co-payments and deductibles) plus claim payments from the carrier. Carriers typically pay a percentage of their allowed amounts. Dental health maintenance organization (DHMO) plans These plans utilize a network of participating dentists who have agreed to provide covered services on a capitated, or per head, basis. Patients are required to select a general dentist who will refer them to specialists for the majority of their specialty care. Compensation is typically a specific dollar amount (usually paid monthly) that is based on how many of the carrier s customers have selected you as their general dentist (a per patient rate). There may be other sources of compensation, depending on the carrier. Preventive services are generally covered at 100%, with co-payments for all other services. Dental indemnity plans These plans, also known as traditional or fee-for-service insurance, allow dentists to provide services at their full fees. The dentists compensation is typically comprised of payments from the patient (coinsurance and deductibles) plus claim payments from the carrier. Carriers typically pay a percentage of the dentists UCR fees and dentists can balance bill to their full fees. Discount dental plans These plans are not insurance, but provide patients with access to specific dentists who have agreed to perform services at a specified discounted price or a percentage discount off of their full fees. These plans, which are mostly purchased by individuals directly and not through an employer, have no deductibles or claim forms; payments are collected directly from the patient. They are typically not regulated in the same manner as insurance products. Government-sponsored programs (Medicaid and SCHIP) These plans are federal health insurance programs that were created to help people, who meet certain guidelines, to obtain insurance. Most of these programs provide minimal or no dental coverage for adults, unless offered in conjunction with supplemental private insurance. Medicaid and State Children s Health Insurance Program (SCHIP) provide dental insurance for children that fall within certain income levels. Benefits vary by state. 3

Pros and cons for dental healthcare professionals Dental plan Pros Cons DPPO DHMO Indemnity Practice growth Typically higher reimbursement based on dentist fee schedule: - Coinsurance and deductibles from patient - Claim payments from carrier Patients encouraged to select a dentist in the DPPO network to lower their out-of-pocket costs Prevents loss of existing patients who transition to the DPPO plan Practice promoted in carrier directory of participating health care professionals PPOs continue to gain market share due to broad appeal to employers Practice growth Steady income from capitation payments (even when patients don t come for visits) Encounter forms generate supplemental payments Patients required to select a general dentist in the network Practice promoted in carrier directory of participating health care professionals No maximums or deductibles Can work on patients without concern for patient limitations Typically higher reimbursement than DPPO based on dentist fee schedule ( full fees ): - Coinsurance and deductibles from patient - Claim payments from carrier Balance billing allowed Patients obtain treatment from any licensed dentist No contracts Contractual relationship Must file claim forms No balance billing Less income from existing patients who transition from an indemnity plan Contractual relationship Per capita payment No balance billing Less income from existing patients who transition from an indemnity plan or PPO plan Patients may leave practice if they join a DHMO or DPPO plan in which the dentist does not participate Opportunities for practice growth may be limited Discount plans Immediate payment; all payments received directly from patients No claim forms to file Increased patient volume Contractual relationship One-to-one billing relationship with these patients can result in greater administrative burden when they don t pay their bills or require a payment plan 4

Focus on DPPOS DPPO networks DPPO plans continue to gain popularity. According to the National Association of Dental Plans, 77% of all dental policies are PPOs. More employers are offering PPOs and more of their employees are enrolling in them due to the greater access and choice provided by these plans. Out-of-network benefits are available, allowing patients to retain existing relationships with out-of-network dentists. When in-network general dentists are selected for care, the savings are even greater. Dental offices that participate in DPPO networks benefit from the upward trend in DPPO enrollments. Reasons for joining a carrier s DPPO network More patients Increased revenue through practice growth Automatic assignment of payments to the dental office Patients enrolled in these plans are more likely to choose dentists in the DPPO network to reduce out-of-pocket expenses Prevent loss of existing patients who join the DPPO plan Patients have asked the dental office to join the carrier s network Promotion of practice in a carrier s health care professional directory Reasons a dentist may choose not to join a carrier s DPPO network Pending retirement or office closing An exclusive contract with another carrier Negative experience with one carrier has negatively affected the dentist s view of other carriers Concern that the practice will be less profitable (less income from existing patients in the DPPO plan) It is a contractual relationship Do not want to submit claim forms and paperwork 5

Focus on DPPOS Features to look for in a DPPO network Not all DPPO networks are created equal. When evaluating networks, be sure they offer these features: Focus on your individual needs A professional recruiter should be assigned to work closely with you to understand your unique goals and practice needs. You shouldn t feel pressured into joining a network plan that doesn t meet your needs or that you don t feel completely comfortable with. The carrier should be responsive, flexible, and offer alternative solutions when needed. Large customer base with national accounts and local employers This will increase the number of patients considering your office for services, and most likely help you retain them in the event they change jobs. Fast and accurate claim payments The carrier should have a history of processing payments quickly and accurately. The carrier should also be able to accept claim submissions electronically, which will increase the speed at which your claims are received and paid. Ease of administration You shouldn t need to make any significant changes in your office procedures and processes to participate in a carrier s network plan. In addition, the carrier should provide resources and tools to help you easily administer the plan, such as: A secure website for quick look up of your patients eligibility, benefits, and status of claims Electronic funds transfer services of payments directly into your bank account so that you may access the funds more quickly Readily accessible representatives when you need them, preferably available 24 hours a day, 7 days a week Dedicated resources to help with more complex issues, such as contract negotiations Works with an independent clinical advisory panel Reputable carriers will work with an independent panel of dentists, who are not employed by the carrier, to actively seek and implement advice on clinical policy recommendations. 6

Common benefit frequency limitations D0120- Periodical Exam: every 6 months or twice a year D0140- Problem focused exam: twice a year D0150- New Patient exam: once or if patient was inactive for 3 years D9110- Emergency Palliative: most plans unlimited, some plans only allow 2 times a year D1110- Prophylaxis-Cleaning: 2 times a year or every 6 months D0274- Bitewings- 4 molar x-rays: once in 12 months or every 6 months D0210- Full Mouth X-ray (FMX): once every 3-5 years (not in conjunction with Panorex D0330) D0330- Panorex: once every 3-5 years D4341/D4342-SRP- Scaling and Root Planing: all four quads in one day or 2 and 2 Arestin: no more than 3 teeth per quad D4910- Periodontal Maintenance: regular check- up and cleaning after SRP: 90 days after SRP must be 4910 not 01110 D1351- Sealants: before age of 16 Fillings: same tooth once a year Crowns/Dentures: replaced every 5-10 years Bridges: Missing tooth clause: claims can be denied if patient s tooth was extracted before the effective date of their insurance. Some dental history follows them to new insurance carriers. Please be aware any references to reimbursement or coding information are for informational purposes only. Selection of appropriate codes is the sole responsibility of the billing party. 7

The Patient Protection and Affordable Care Act (ACA) The health care industry can expect significant changes due to the provisions of ACA, also known as the Affordable Care Act. From changes in health insurance benefits, to how your patients can purchase insurance coverage, these provisions will affect nearly everyone who delivers or consumes health care in the United States. What is the Affordable Care Act? The Affordable Care Act, or ACA, is a new federal law. It requires non-grandfathered, insured health plans offered in the individual and small group markets (both inside and outside of the Exchanges) to provide a core package of health care services, known as essential health benefits. What are Exchanges? A provision of ACA, the Health Insurance Exchange, also known as the Health Insurance Marketplace, is a new option through which individuals and employers can purchase medical and dental insurance. Exchanges were required to be operating in every state by January 1, 2014. Does ACA affect dental coverage? Yes. One requirement of ACA ties to the provision of pediatric dental coverage for individuals up to the age of 19. Plans of all sizes that cover benefits designated as essential health benefits by the state benchmark plans (including self-funded non-excepted dental and vision plans*) cannot apply annual or lifetime dollar limits on pediatric dental services that are defined as essential health benefits. In addition, dental coverage cannot be denied for persons of any age based on preexisting conditions, including benefit limitations and coverage denials. * Self-insured dental and vision benefits are considered non-excepted when employees who enroll in medical coverage automatically receive dental benefits, vision benefits, or both, and/or are not required to pay an additional contribution for them. If insurance reimbursements are a concern for your office, Henry Schein can help. Contact your Henry Schein Sales Consultant to schedule an insurance presentation, call 800-372-4346 or visit www.henryscheinbusinesssolutions.com. 14DL2398