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Policing the Insurance Policies by Tina Byrne

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Policing the Insurance Policies

A deep dive into the insurance world can net profit for any practice


by Tina Byrne

Possessing a keen understanding of orthodontic insurance and the continuous changes within the industry is, and always will be, an essential business ability. Many orthodontists are illiterate in this area of practice; they are unfamiliar with the trends, the networks or affiliations and, most notably, the modifications made to benefit plans that affect both patients and providers. I advise doctors to be aware of insurance and all it entails, regardless of the provider’s depth of engagement.

Unknowns of plan participation

To be an in-network provider and participate with a plan is not necessarily a “discount death sentence.” To the contrary, a strategic approach to contracting, coding and claim submission could yield tremendous growth in a practice. Truth be told, I frequently come across arbitrary courtesy percentages that exceed the discounts for in-network participation.

The manner in which you contract to be in-network is also a consideration. Providers have an option to participate either directly or indirectly with many (but not all) insurance carriers. Indirect participation presents an opportunity for providers to acquire higher fee allowances.

For instance: A doctor chooses not to be in-network with Assurant, because Assurant has very low maximum allowable charges (MAC). However, Assurant is also an affiliate of United Concordia, which has a very high MAC. Participation with the Assurant carrier through United Concordia means the doctor will be contracted for the higher United Concordia allowances for Assurant patients.

The discovery of and inquiry into networks and their affiliate carriers can be extremely time-consuming, as can be the drawn-out process of credentialing and negotiating fees. My go-to, and without question the best source for researching your geographical area and obtaining the highest fee allowances, is Five Lakes Dental Practice Solutions.

Just an FYI: 82% of all individuals with dental insurance have PPO plans.

Benefit changes

Increasingly, patients are presenting to orthodontic offices with traditional or PPO plans that provide larger- than-typical dollar benefit amounts for orthodontic treatment. I’m referring to huge amounts like $5,000 or $6,000; I’ve seen as high as even $8,000.

“The bigger the benefit, the less to be paid by the patient.” That’s the preconceived notion patients and parents bring to your office, along with their excitement for having to pay very little, if any, out-of-pocket. Any treatment or insurance coordinator will attest to having to “burst the euphoric bubble” and be the bearer of bad news as to how it works! We are having to increasingly educate patients with a detailed explanation of orthodontic benefit calculation—and the expected amount to be paid—in addition to limitations, restrictions or exclusions that may be reducing their benefit. It is becoming more evident there is no clear disclosure of the benefit details at the time of benefit election.

I understand that insurance is a business, and plans offering large-dollar amounts for benefits are well received by employers and sought after by employees, particularly those with orthodontic care on their horizon. Another revelation: These plans are likely going to be in effect for no more than two years, meaning there is little to no chance that subscribers will receive their full orthodontic benefit.

For patients encountering a change of insurance plan while in active orthodontic treatment—and there are many—a “transition of care” clause within the new carrier plan assuredly will be in place. Numerous major carriers are now writing terms and conditions into contracts that ensure the total benefit paid between multiple carriers does not exceed the lifetime orthodontic maximum under one single plan.

I recall a time not so long ago when a patient could look forward to a “renewed” benefit, which likely translated into a higher amount to be paid than originally expected. Not anymore!

Comprehensive verification reduces mistakes

I rarely encounter an office that doesn’t verify eligibility and benefits for a patient before presenting treatment and a fee. I do see many offices obtaining only a bare minimum of the information they deem necessary for benefit calculation. Be cautious that the omission of additional detailed benefit info isn’t resulting in overdue insurance accounts and write-offs because of inaccurate calculations.

Online access and fax transmission remain quick methods of obtaining benefit data, although only 80% of the plan details are received. Numerous and relevant specifics of the benefits are often not disclosed. Usually, the exclusion of essential data results in benefit error. A telephone inquiry to a carrier representative continues to be the most productive—but agonizingly tedious—approach to obtain all benefit particulars.

For quite some time, dental deductibles were rarely applied to an orthodontic treatment. Now we encounter orthodontic-specific deductibles, which appear to becoming more and more prevalent. I have seen orthodontic deductibles as high as $250 annually. This calculates to a significant oversight if not discovered during a benefit verification process.

Out-of-network offices, be on alert: Carriers are more frequently calculating benefit payments using an internal UCR (“usual, customary and reasonable”) fee—not the orthodontic fee submitted by your office—even though you are nonparticipating. This method of benefit calculation by carriers may have been in place for some time, but is coming into play more frequently because of the increased dollar amounts of benefits.

An example: You have a nonparticipating office fee of $5,600 and a patient benefit paid at 50% of the fee, up to a lifetime maximum benefit of $2,500. You calculate an expected benefit of $2,500. However, the carrier uses its own UCR, which is set at $3,900—paid at 50%. Now, the benefit they are paying is only $1,950 and you have overestimated this benefit payment by $550.

Through computations of my own, it appears some UCRs are grossly reduced by the carrier and not a realistic average of fees in any given area. The UCRs are also less than the MAC for the carrier’s in-network providers. To complicate this matter, carriers refuse to disclose the amount of their UCR.

A little expertise goes a long way

Doctors, make certain your team is taking a deep dive into patient insurance benefits, as well as staying on top of overdue carrier remittances. If you’re unfamiliar with this area of your practice, get to know it! Insurance benefits can average 20% or more of a practice’s receivables.

I’ve always believed it’s an advantage for the team member(s) accountable for claims and insurance receivables to also be the person posting benefit payments in an office. A review of every explanation of benefits (EOB) that accompanies payments is necessary in identifying payment discrepancies and/or the lack of remittance frequency. Secondly, overlooking the codes and explanations that could appear on EOBs is the No. 1 reason for overdue or uncollectible insurance benefits. The posting of benefit payments is anything but a simple, mindless task!

Orthodontic practices that achieve success with plan participation and the management of benefit receivables are those with an exceptionally competent source within the office who remains well informed of carrier developments, stays on top of benefit plan particulars and is discerning with claim submission.

One final happening with insurance that truly gets my goat: Benefit payments being issued through virtual credit cards. Your office is incurring transaction and merchant fees to post those remittances.
  
Author Bio
Tina Byrne With more than 40 years of experience working and consulting in the field of orthodontics, Tina Byrne has gained success and recognition for her proficiencies in clinical, business and administrative functions. She has extensive knowledge and understanding of systems innovation and efficiency, data analysis, strategic business planning and marketing implementation. Byrne, who has lectured and helped guide the success of leading practices throughout North America and abroad, is the only industry consultant who has extensively trained and lectured on orthodontic insurance. She has developed an orthodontic benefit maximization program for in-network providers, scheduled for release by OrthoFi and OrthoBanc in 2021. Email: tinabyrne@byrne-consulting.com


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