The Dos and Don’ts of Navigating Dental Insurance

Many of today’s patients rely heavily on their dental insurance to help offset the cost of treatment. Practices that accept or network need the right tools when it comes to navigating the world of dental plans. They also need to know how to effectively communicate with patients about their plan’s benefits.

In addition to acting as a mediator between your practice and a patient’s insurance plan, it is important that you know the common limits of most insurance plans. This way, you’ll be able to predict copayments more accurately, saving you time and money.

Here are the dos and don’ts of dental insurance to help you get a head start.

1. DON’T tell patients that insurance will “pay” or “cover” when talking to them about insurance reimbursement. It creates an expectationfor their dental plans to cover the procedures, which can never be guaranteed. Using the right terminology will save you from having to explain why someone’s insurance didn’t pay for a procedure you told them would be covered. DO use words like “estimate” to let patients know that the co-payment you pay them is not a guarantee of payment.

2. DON’T volunteerProvide patients with a detailed explanation of their dental plan benefits. The plan is a contract between patients and their insurers. It is not your responsibility to educate them on their benefits. This information should be obtained directly from their insurance plans or group administrators. DO Respond candidly when patients inquire about the benefits of their regimen. If they ask you, only provide them with the basic information provided by their plans, such as maximums, deductibles, and coinsurance amounts. If necessary, refer them (kindly) to their dental plan or human resources department if they want to know more about their coverage.

3. DON’T call the insurance company for a breakdown of benefits, especially to verify eligibility. It takes a long time and you never know if you are receiving accurate information. Additionally, they will have a recording of the call and can use it to send patients back to the office. DO obtain benefits online whenever possible. This is the most accurate representation of what a patient’s plan provides. Plus, you’ll have actual proof of benefits, including date and time, on file, saving you time and headaches on appeal.

4. DON’T assume that fillings are still covered at the composite rate. Most plans will apply another benefit to posterior resin composites and reduce the payment to that of an amalgam filling (money). This reduces the amount reimbursed to your practice and increases the patient’s financial participation. The same goes for crowns – many dental plans will downgrade them as well. DO read the fine print in the breakdown of benefits you get online, or if you end up calling, ask if composites and crowns are downgraded. If you are unable to get this information, assume there is a downgrade. Once you have received the Explanation of Benefits (EOB), you can reimburse a patient if the insurance pays more than expected.

5. DON’T assume a patient is eligible when they present for their biannual examination and cleaning. Some schemes operate on a tax basisyear and some patients end up getting new dental coverage or they have no insurance at all. DO perform an eligibility check every six months and always check that benefits, including maximum and deductible, match what your office has on file. Often insurance plans change the details which, if not checked, can lead to complications such as inaccurate co-pay information.

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Helen B. Funk has worked as Office Manager for Cosmopolitan Dental since its inception in 2006. As the primary patient liaison, Helen’s goal is to greet patients in a professional, knowledgeable, and personable manner. Helen is currently enrolled at NYU and working towards a certificate in Leadership and Organizational Development. She is keen to make sure the office is running smoothly from reception. In her spare time, Helen enjoys writing, travelling, doing yoga and exploring new restaurants in New York.


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