Understanding Dental Insurance – FAQs

With so many ins-and-outs to work through when opening a new practice, dental insurance may be one of the big ones keeping you awake at night. Below are some of the most frequent insurance FAQs we hear.

Q: What types of Dental Insurances are available?

A: There are a number of them.

• Regular Dental or Indemnity Plan
• PPO – Preferred Provider Organization
• Medicare – Government Administers
• Capitation – Provider gets paid a set amount for each patient in their practice covered by this plan.
• HMO – Health Maintenance Organization
• Direct Reimbursement – The patient pays the office and then is reimbursed by their employer for dental treatment.
• Corporate Model – Willamette, Kaiser, Gentle Dental

Q: Which type of plans do you see most often?

A: These two are the most common:

• Indemnity/Regular Insurance
• Preferred Provider Organization

Q: What’s the difference between regular dental insurance plans vs. a PPO plan?

A: There are a handful of ways to determine the difference:

• The practice may charge their UCR (Usual, Customary, and Reasonable) fees for standard insurance plans while they are committed to a fee schedule provided by the insurance company for a PPO plan.
• If the practice UCR fee exceeds the insurance company’s UCR fee with regular insurance, the patient may be billed for the difference.
• With PPO insurance, the practice is required to write off the difference between the PPO fee schedule fees and their UCR fee.
• Even if the treatment is not covered by the PPO plan or the patient has reached their maximum for the year, the practice may still be required to use the PPO fee schedule when billing for those services.
• Once a practice has signed a contract with a PPO, they are committed to their rules and regulations even if they vary from the ADA standard of care.

Q: Why/how would a practice choose to participate in a PPO plan?

A: Ultimately, your practice can benefit like this:

• Signing up as a PPO provider can be a source of new patients for the practice. The Doctor is listed on the insurance company website, and potential patients are driven to them as a preferred provider.
• A large employer in the area changes insurance plans for the employees, and the practice has a large percentage of their patient base offered by this new plan.
• The practice is getting too few new patients without becoming a PPO provider.
• The practice has too many open hours in both Doctor and Hygiene columns each month.

Q: How does a practice decide which plans to participate in?

A: Take a look at the following:

• Request information from the plans, including a copy of their fee schedule. See what the percentage of the write-off would be when compared to the fee-for-service fee schedule.
• Know which procedure codes are utilized most. Those are the fees the practice would assign top priority during fee negotiations.
• Review the agreement with the insurance company to see what restrictions come along with this plan as well as any other plans that might fall under this company’s “umbrella.”
• Is the office receiving requests from an existing patient base to add this PPO plan?

Q: What can the practice do to receive payment as quickly as possible?

A: Follow these four steps:

1. Check each claim before it is sent to ensure all needed information is included on the claim form.
   • Billing correct insurance plan and sending to correct address
   • Name of employee
   • Name of patient, if different
   • Is the patient covered by another insurance company
   • Date of birth
   • Gender
   • Relationship to employee
   • Group number
   • Subscriber number
   • Date of treatment
   • ADA Code number
   • Tooth/quadrant number
   • Surfaces treated
   • Assignment of benefits to practice box checked
   • All practice information correct
2. Make sure to attach all supporting documentation.
   • Copy of pre-authorization, if applicable
   • Copy of x-rays and/or intraoral photos
   • Perio charting if perio treatment was rendered
   • A comprehensive narrative regarding treatment rendered
   • Copy of EOB from primary insurance if this is secondary coverage
3. Submit claims electronically at the end of each patient day.
4. Run “unsubmitted claims report” once a week to verify all claims have been sent.