The Ultimate Guide to Understanding Dental Insurance Billing
For a dental practice owner, understanding dental insurance billing is paramount. Learning insurance billing is vital for patient satisfaction and helps dental practices ensure they get paid for the services rendered.
However, dental insurance billing is not a simple code to crack. Successful dental practices realize the importance of understanding dental insurance billing and how it is not one man’s job and requires a dedicated team with substantial knowledge of dental billing.
Knowing how crucial it is to learn dental insurance billing for your practice’s success, you might want to know more about it. Good for you because this is precisely what we will discuss regarding legal dental insurance billing.
What is Dental Billing?
Dental billing is the process that involves submitting claims for dental services rendered by the practice and following up on them for reimbursement. This process is not as easy as it may seem. It requires preparing and submitting claims to either the patient themselves, the insurance company, or the government programs.
Once claims are submitted, they are tracked until they are billed. However, if a claim is denied or rejected, it should be evaluated for any errors in the billing process. The claim is then resubmitted to the insurance company.
How Does Dental Billing Work?
Dental practice owners should understand the billing process to ensure smooth dental billing, even if they outsource billing.
The dental billing cycle comprises multiple steps, which can be learned through this simple step-by-step guide:
Step 1: Gather Patient Information
The first step in the dental billing cycle is collecting patient information, typically during the appointment scheduling. This includes the patient’s name, contact details, residential address, email, insurance plan, and insurance ID number.
Step 2: Verify Insurance Eligibility
After collecting insurance details, verify the patient’s eligibility directly with the insurance company or through an electronic system. This helps avoid denied or rejected claims.
Step 3: Perform Dental Services and Document Treatment Codes
Once eligibility is confirmed, the dental practice provides services. Procedures are recorded with treatment codes, dates, and fees. This information is entered into the billing software and sent to the insurance company for reimbursement. Accurate documentation ensures timely and correct payments.
Step 4: Submit Claims
After services are provided, claims are submitted to the insurance provider by mail or electronically. The practice should track the claim’s status to ensure timely payment.
Step 5: Follow up on Claims and Resolve Issues With Outstanding Claims
Monitor claims after submission to ensure processing. Follow up with the insurance company if a claim is denied or delayed. Identifying and resolving issues quickly ensures timely reimbursement.
Step 6: Receive payments
Once the insurance company processes the claim, verify that the payment matches the fees for services rendered. The medical billing team and the insurance company should address any discrepancies.
Understanding Dental Insurance Plans
Dental insurance can pay for dental bills, but it can be hard to understand the terms and conditions. For dental insurance to work, the insurance company, the dentist, and the patient generally have to work together. Your plan will affect how much you pay out of pocket, what services are covered, and which doctor you can see.
Fee-for-service dental insurance plans are the most common type. The user pays some of the cost, and the insurance company pays the rest. You must know your plan’s maximums, deductibles, co-pays, and fees. By learning these terms, you can make better choices about your dental care.
Types of Dental Insurance Plans
There are several types of dental insurance plans, each offering different levels of coverage and flexibility:
1. Preferred Provider Organization (PPO) Plans
PPO or Preferred Provider Organization plans are considered rather popular among the various types of dental insurance. It presents a network of providers willing to give the plan members lower prices in exchange for customer referrals. The patient has the right to select any dentist of choice.
However, it will be economical to visit the network dentist. PPO is the preferred provider organization plan that tends to pay for preventive care services at a higher percentage. In comparison, services such as surgeries are paid out at a lower percentage.
2. Health Maintenance Organization (HMO) Plans
3. Indemnity Plans
They are sometimes referred to as fee-for-service or classic dental insurance; indemnity plans are the most flexible in that they can be used where all your dentists of choice like. Usually, the insurance firm reimburses a certain percentage of the total cost of your dental care, and you have to pay the rest. Such plans may cost more than other insurance plans, and they may make you pay first and then reimburse you in some amounts.
4. Dental Discount Plans
Dental discount plans are not insurance; individuals pay an annual subscription fee to be given a discount on services rendered by the dentist. You must go to the participating dental practitioners to benefit from the offer. These plans are ideal for people who do not have dental insurance coverage or those who wish to have extra discounts on out-of-pocket expenses.
There are various dental insurance plans one can choose from, and the critical aspect of choosing the right one is understanding the various types of insurance programs. Regardless of the preference for flexibility, lower premiums, or particular types of insurance, the information on available choices will enable a proper decision.
Key Terminologies in Dental Insurance Billing
Both patients and doctors must understand dental insurance billing terms. These words are crucial for billing, ensuring correct payments, and keeping things clear. Important key terminologies in dental insurance billing are :
1. Deductible
The amount a patient pays out-of-pocket before insurance coverage kicks in, typically annually.
2. Coinsurance
The cost-sharing arrangement is where both the patient and the insurance plan pay a portion of the dental bill, usually after the deductible is met.
3. Pre-existing Condition
A dental issue that existed before enrolling in an insurance plan. It is commonly referenced in clauses like the “missing tooth clause.”
4. Amount Allowable
The maximum amount an insurance company will pay for a specific dental service.
5. Allowable Charge
The portion of the cost a patient must pay for a service when the insurance plan doesn’t cover it.
6. Non-Billable to the Patient
A service not paid by the plan and not billed to the patient is often related to PPO contract stipulations.
7. Balance Billing
Charging the patient the remaining balance after the insurance plan has been paid primarily applies to out-of-network services.
8. Negotiated Fee or Contracted Fee
The agreed-upon rate between a dental provider and a PPO plan is often lower than the standard fee.
What is The Importance of Dental Billing?
In the U.S., 65% of dental practices work with dental insurance, and 50.2% of the U.S. population avails of dental insurance. This proves that dental insurance billing is an integral component in managing the revenue cycle of dental practice.
Dental insurance billing is important for the following reasons:
- Offers Reimbursement
Efficient dental insurance billing is integral for receiving reimbursements for the dental services offered to patients. It is necessary to have a streamlined billing and coding process for efficient cash flow. This ensures the financial stability of the practice and helps it to thrive.
- Helps With Record Keeping
Due to the dental billing process, the entire patient record is managed in an organized manner. Dental practices can ensure timely reimbursement by accurately recording and processing insurance claims. This not only improves cash flow but also helps track the practice’s financial progress.
- Reduces Denied Claims
Accurate dental insurance billing can significantly help dental practices reduce their claims from getting denied. However, to achieve this, dental practices should comply with the latest regulations of insurance companies and government policies regarding dental billing. By adhering to these regulations, dental practices can ensure they are billing correctly. Ultimately, this mitigates the risk of legal consequences.
- Results in Patient Satisfaction
Dental practices that offer transparency in their billing services gain the trust of their patients. This level of transparency builds trust between the patient and dental practice. Moreover, it also results in a positive patient experience. Ultimately, patient satisfaction can increase loyalty and referrals, benefiting the practice.
Common Challenges in Dental Billing
Dental billing professionals must navigate various challenges to ensure accurate and timely payments. Below are some of the most common challenges faced in dental billing:
1. Insurance Verification and Pre-Authorization
Before every procedure, dentists must verify patient insurance to assure coverage. Insurance claims denied without verification might delay or cost money. Insurance companies may need pre-authorization for various operations, which might delay treatment.
2. Complexity of Dental Codes
Dental billing codes, especially CDT codes, are broad and difficult to handle. To avoid claim denials, dental procedures must be coded correctly. Misusing outdated or inaccurate codes can cause claim denials, resubmissions, and payment delays.
3. Frequent Claim Denials
These are time-consuming because test claim denials will escalate billing challenges that will impact the time and energy used to deal with the same. To avoid disrupting its positive cash flow, it is important to comprehend the usual causes of denials and make checks to prevent them.
4. Patient Billing and Collection Issues
People getting treated in hospitals can be a nightmare regarding billing and collection. Those patients who fail to pay their bills are usually seen as a source of discomfort to dental practices. These are some of the challenges likely to be faced during payment; therefore, there is a need to embrace effective communication of payment responsibilities.
5. Keeping Up with Regulatory Changes
Regulations, insurance policies, and code modifications often change in dental billing. Keep up with these developments to avoid compliance concerns and maintain correct billing. Dental clinics must train and update their billing systems to react to these developments.
6. Time-Consuming Administrative Tasks
It can be challenging for small offices with a small team to handle dental bills. Filing claims, following up on claims that were not paid in full, and dealing with patient issues can use many resources for patient care. Outsourcing dental billing and setting up regular billing can help you relax.
7. Balancing Productivity and Accuracy
It takes a lot of work for dental offices to keep up with accurate bills and workflow. It’s important to handle claims quickly, but wrong billing can cause claims to be denied or payments to be held up. Speed, accuracy, and process must all be present in dental offices.
Pros and Cons of Outsourcing
Pros
- Professional billing companies hire dentist coders who know how insurance rules work, the best practices, and the latest standards. Their knowledge reduces denied claims and speeds up payouts by eliminating mistakes.
- Outsourcing saves money on pay, benefits, and office space by eliminating the need for an in-house billing team. Higher profits and speed from outsourcing balance out costs.
- Claims and reimbursements are processed quickly by a specialized billing team. This steady income can help the practice’s funds stay stable.
- Outsourcing billing frees dental staff time for patient care and other responsibilities, enhancing patient satisfaction.
- Outsourcing lets practitioners expand their billing operations to patient volume variations without adding staff.
Cons
- Outsourcing entrusts an important practice function to an outsider. This raises worries regarding service quality, data security, and billing control.
- Working with an external billing business can cause communication issues, especially if the supplier is in a different time zone. Smooth operations require clear and constant communication.
- Overreliance on a third-party supplier might make switching providers or bringing billing in-house complex.
- Outsourcing can save money, but there may be hidden fees. Practices should thoroughly evaluate contracts and comprehend all costs.
How to Choose the Right Billing Service Provider
Your dental practice’s success depends on choosing the correct billing service provider. Important considerations when choosing a billing service provider:
- Industry Experience and Expertise
- Reputation and References
- Range of Services
- Technology and Software
- Data Security and Compliance
- Communication and Customer Support
- Pricing Structure
- Flexibility and Scalability
Outsourcing Dental Insurance Billing
Outsourcing dental insurance billing assists the practices in attaining efficiencies and reducing botheration. Hiring professional billing companies to contract dental insurance billing services will prevent some of these mistakes and aid in enhancing the claim process and maintaining healthy revenue cycles.
Contact HMS USA for customized dental insurance billing services. Our team fully supports your billing processes to ensure they are optimally effective and error-free. Contact us immediately to address how you bill and, most importantly, how much money your office generates.
FAQs
Dental billing is a complicated field and learning it can be challenging too. However, when equipped with the right resources and the devotion to learn one can understand how dental billing works.
A dental healthcare provider should focus on the reason for the claim being denied and resubmit it with corrections if necessary and appeal the decision if the need arises.
CPT code D2740 is used to record the procedure of porcelain or ceramic dental crowns.
For anesthesia in the dental office, CPT code 00170 is used.
D7240 is the CPT code used to document the removal of the impacted wisdom tooth which is completely bony, whereas, the CPT code used for the documentation of impacted wisdom tooth which is partially bony is D7230.
