In the world of dentistry, dental insurance companies are always updating and changing their policies. This doesn’t just affect your dental patients, it affects your claim submission process, as well.
Most insurance companies implement changes at the beginning of every year. It’s crucial for you to stay abreast of these modifications to ensure fast claim reimbursement, and also to communicate to your patients when their coverage has changed.
Every dental patient’s coverage is different, and it’s impossible for us to list every dental insurance provider’s changes here, but there are three things that tend to be adjusted every year.
Let’s talk about 3 big insurance policy changes you need to look out for as you schedule your 2024 appointments.
Payer Change #1. Annual maximum
An annual maximum is the amount the insurance plan will pay for covered dental services within a given calendar year.
Knowing a patient’s annual maximum is critical for treatment planning and financial discussions. When you know a patient’s annual maximum, you are able to spread out their treatment over time to ensure they’re not paying excessive out-of-pocket expenses.
Related: 4 ways to help patients use their dental benefits by end of the year
With this in mind, the patient’s annual maximum can change — and not always to their advantage.
If the annual maximum is lowered for any reason, your patient might not receive as much coverage as you both anticipated. And if your team isn’t aware of this, you might face a claim denial, have to collect more from your patient than they’re prepared to pay, or both.
Payer Change #2. Coverage amount
Every year, there may be changes to the amount of coverage each patient has. Coverage changes can affect their eligibility, exclusions, or clauses in their insurance coverage.
For example, a missing tooth clause could be added to the insurance policy. This clause treats a missing tooth as a pre-existing condition. It will not cover any dental treatment — whether fixed partial denture, removable partial, or implant — that replaces a tooth which was extracted or missing prior to the date the insurance coverage started.
This addition to a patient’s policy is a perfect example of essential information your team needs to know, as it directly affects the patient’s out-of-pocket expenses.
AADOM explains:
“Carriers are downgrading or changing procedure codes to an alternative benefit. Because an insurance company has the ability to change codes to procedures with lesser benefits, patients need to be aware that this policy can or may impact their coverage.”
They continue:
“You will want to inform them that the dental insurance company maintains the right to do so, and that they might list certain procedures as being uncovered. In such circumstances, the patient needs to be aware that they will be financially responsible for any difference in fees.”
These changes impact billing, as well as the treatment timeline for the patient. You might choose to split the patient’s treatment into separate visits to make out-of-pocket payments more manageable, or offer a payment plan to split up the payments over time.
Payer Change #3. Adjusted deductibles
A deductible is the amount a patient must pay out-of-pocket before their insurance begins to cover services. This is a term your team needs to understand for insurance verification, and more specifically, for the treatment presentation.
Deductibles are another change that directly affects your billing, as it determines when a patient’s insurance coverage finally kicks in.
Read more: DCS Dictionary: Dental Insurance Verification Terms
There are two types of deductible structures: Individual and family. Each works a little differently, but what they have in common is the patient must pay an out-of-pocket amount that surpasses the deductible before insurance will begin covering costs.
Submitting a claim before deductibles have been satisfied guarantees a denied claim, and your patient won’t appreciate receiving a bill for treatment that your team told them was covered by insurance.
Many deductibles will cover preventative treatment, such as oral exams and teeth cleaning, but as we’ve said — deductible amounts are subject to change, and they usually reset to $0 paid out of pocket for all patients at the start of every year.
How your team can avoid claim issues due to insurance policy changes
To avoid issues with insurance policy changes, get a full breakdown for every patient in the new year during your insurance verification process.
Even if a patient’s insurance provider or employer hasn’t changed, the items we mentioned above, and many other policy rules and guidelines, are still subject to change.
Once your team has the full breakdown of a patient’s insurance policy, they should review it prior to the patient’s appointment, then go over any changes with the patient during the treatment presentation.
They must remind your patients that regardless of their insurance coverage, they are ultimately responsible for the cost of treatment, and the out-of-pocket amount presented to them is only an estimate.
Related: 3 tips to successfully communicate your patient's dental treatment plan presentation
If insurance policy changes affect their coverage or treatment plan, and you clearly and transparently communicate this to your patients, you’ll minimize pushback after they receive their bill.
If your patient feels like the costs are too much, explain why their treatment is valuable to them, and go over payment and financing options.
Insurance verification is essential before every appointment, and it is especially important around the new year when there are possible payer policy changes.
Our top tip: Partner with insurance billing experts to keep up and implement these dental insurance changes
To recap, here are the 3 big insurance policy changes you might see at the start of every year:
- Payer Change #1. Annual maximum
- Payer Change #2. Coverage amount
- Payer Change #3. Adjusted deductibles
Make sure your team gets a full breakdown of each patient’s coverage at the beginning of the year and notes any changes that need to be communicated to the patient. It’s an extra step worth taking to avoid billing problems and maintain patient satisfaction.
Our revenue cycle management services at DCS will help your team stay up to date on changes like these for cleaner, faster claim submission, as well as easy patient billing and collections.
Face 2024 with confidence: Book a call with DCS.
Related Posts
Dental billing resources