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    8 ways to make insurance less of a pain

    Insurance can be frustrating for any practice, but these tips can put you and your patients at ease.


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    3. Use the PPO manual

    “Where there’s a disconnect of information is on insurance administration,” Dr. Blair says. “We’re up to the point where there are about 14 PPO plans per each indemnity plan.”

    Dr. Blair says that the lack of knowledge that practices have in the PPO arena is “troubling.”

    “For instance, everybody knows that there is a contract with the PPO, but nobody knows that the contract says you are supposed to adhere to the processing policy manual. That manual might be 150 pages. It really spells out the relationship between the practice and the PPO.”

    The manual outlines several aspects of reimbursements that many practices may not be aware of such as how to handle optional services, the need to report all charges, the option to reject or disallow procedures, and how to handle “dual” insurance.

    Related article: 5 best practices for fee schedules in the dental practice

    For handling optional services, Blair gives this example: “If I were doing a very complex case — a $25,000 or $30,000 case — and my crown fees are $1,000, I can’t level arches and do provisionals and everything for $700, which is the PPO fee,” Dr. Blair says. “So, I get an exclusion. That’s one thing in that processing policy manual.”

     Blair also stresses the need to report all charges, which he says includes tooth whitening. “They are supposed to be sent to the PPO for review,” he says, “even though they’re not going to pay for certain procedures. For instance, they would not pay for tooth whitening, but they might control the fee. We call that fee capping for non-covered procedures.”

    Plans can also deny or disallow procedures. “Deny means they’re not going to pay it, but you can collect from the patient,” Dr. Blair says. Disallowing a procedure “means the insurance won’t pay and you’re prohibited from charging the patient.”

    He argues that a lot of offices leave money on the table between denied and disallowed procedures.

    Dual insurance comes up about 15 percent of the time, Dr. Blair says, and many practices don’t realize that the benefits are coordinated and that the practice can collect up to its full fee.

    If the dentist treats a dependent who is under both his or her mother’s and father’s insurance plans, the doctor can be reimbursed through a coordination of benefits. “The doctor could be in two low-fee PPO plans and actually get their full fee,” Dr. Blair says. “That means that we get two checks. A lot of offices don’t realize that — they want to give money back because they think they’ve been overpaid. But if I put $1,000 on the claim form, then I can keep up to $1,000. I have not been overpaid unless I get above the fee that I place on the claim form.”

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