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QUESTION: We had some confusion between primary and secondary insurance. My question is, what fees should we follow, primary or secondary? And if the primary is lower than the secondary? Also, what happens when the primary says a patient owes one amount and the secondary says the patient owes another. How much does the patient pay?
ANSWER FROM CHRISTINE TAXINfounder of Links2Success:
Each type of insurance follows a different set of rules. You need to know if your state has policies that don’t allow this to happen, such as California’s rule that prevents non-duplication of benefits. This allows the office to charge and collect the highest fees, not the lowest fees.
The difference between the dentist’s full fee and the sum of all dental plan payments and patient payments is the amount of the write-off. Write-offs should not be accounted for until all plans have paid accordingly. If a write-off is recorded after the primary insurance payment and then recorded again based on the secondary payment, it is possible that the dental office is incorrectly applying a credit to the patient’s balance. Remember to always submit your full expenses on the dental claim form.
Here are a few ways you might need to opt out depending on the plan you’re charging.
- When filing for both primary and secondary insurance, you must charge your full fees to the patient register.
- You must submit a primary claim and secondary claims. The patient is only responsible for the fees up to the lower of the two insurances. For example, if a crown’s charge is $700 from one insurance company and $800 from another, the patient is only responsible for their share up to the lower charge of $700. . If the practice receives $700 or more from both insurances, the patient owes nothing. The office is authorized to collect up to its office fee. If the office receives more than its office expenses, it must reimburse the insurance company. The patient does not receive any part of the fees collected by the practice.
Types of Coordination of Benefits (COB)
Many factors determine how COB is handled, including state laws, applicable carrier treatment policies, contract laws, fully insured versus self-funded plans, and the types of COBs used. There are several different types of COBs that blueprints can use. Here is a brief description of some of the more common methods:
- Traditional: Traditional coordination of benefits allows the beneficiary to receive up to 100% of the expenses of a combination of the primary and secondary plans.
- Continuation of Benefits (MOB): This reduces the covered expense by the amount paid by the primary plan, then applies the plan’s deductible and coinsurance criteria. As a result, the plan pays less than it would under a traditional COB agreement, and the beneficiary usually ends up with a portion of the costs.
- Slicing: Slicing is a coordination method that first calculates the normal plan benefits that would be paid, then reduces them by the amount paid by the main plan.
- Non-duplicating COB: In the case of a non-duplicating COB, if the primary carrier paid the same amount or more than the secondary carrier would have paid had it been primary, then the secondary carrier is not liable for no payment. Non-duplication is typically used in self-funded dental plans. A self-funded dental plan is one in which the plan sponsor bears the entire risk of use.
- Self-funded plans are exempt from state insurance laws and are generally governed by the Employees Retirement Income Security Act (ERISA). In 2012, 49% of people with a dental benefit had a self-funded plan. (. It is important for dental offices to understand that not all patients will have a dental plan subject to state COB laws. ADA policy opposes non-duplication provisions, and at least one State, California has enacted legislation prohibiting such provisions.
Network plan write-offs
The difference between the dentist’s full fee and the sum of all dental plan payments and patient payments is the amount of the write-off. Write-offs should not be accounted for until all plans have paid accordingly. If a charge-off is recorded after the first payment and then recorded again based on the secondary payment, it is possible that the dental office may mistakenly apply a credit to the patient’s balance. Remember to always submit your full expenses on the dental claim form.
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Do not be shy ! If you have a tough problem in your dental practice that you want to solve, send it to [email protected] for the experts to answer. Don’t forget that you will be helping other people who share the same problem. Answers will come from various dental consultants and experts in HR, coding, front office management, and more. All inquiries will receive an anonymous response on DIQ.
Originally published in 2017 and updated regularly
