Coordination of benefits (COB) is a complicated part of insurance administration.

Coordination of benefits occurs when a patient is covered by more than one dental benefit plan. When this is the case, various questions arise. In what order should claims be filed? How much will the various plans pay and how much will the patient be responsible to for? Once all parties have paid their respective portion of the bill, what will be the required write-off?

To further complicate the COB issue, patients often have a misconception about the way payments are handled when they are covered by multiple plans. Many patients believe that being covered by more than one plan ensures that their insurance companies will pay the entire dental bill and the patient will not owe anything. When a patient learns that there is a balance to pay, dental staff have to explain why a payment is required. This can be a difficult conversation, especially when the patient firmly believes that the practice should absorb the remaining costs. Thus, it is important to have a proper understanding of coordination of benefits to avoid misconceptions and issues with your patients.

Order of Coverage – The Basics

With COBs, the first step in billing for dental procedures is to determine which plan is the primary plan. While the National Association of Insurance Commissioners (NAIC) has published various guidelines for determining the order of benefits, these guidelines are not law. Each state has the option of creating its own COB laws; however, self-funded plans follow federal law (ERISA), not state law. While most plans follow some version of the NAIC guidelines, there can be many variations for determining the order of benefits.

Despite the many variations you may encounter, here are some basic guidelines that the majority of plans follow. While there are exceptions to these rules, you can generally use the following as a guideline:

• Employee vs. Dependent
•  The plan that covers the patient as an employee (or subscriber) is primary to the plan that covers the patient as a dependent.
• Current Employment vs. Prior Employment
•  The plan that covers the patient as an active employee is primary to the plan that covers the patient as a terminated employee. Note: This typically includes COBRA and retiree coverage.
• Coverage by Multiple Active Employers
• The plan that has covered the employee for the longest period of time is primary.
• Dependent Children
•  For patients with parents who are married or have joint custody, the birthday rule usually applies. This means that the parent whose birthday is earliest in the calendar year (without regard to age) is primary. For children with divorced parents, the court-ordered divorce decree will determine the order of coverage.
• Medical vs. Dental Plan
• When medical benefits are available for treatment performed by a dentist, the medical plan is typically primary to the dental plan.

Dental benefits differ from plan to plan; therefore, it is important that as much information about each plan be learned, especially since those different policies will affect the financial arrangements dentists make with patients. If the benefit criteria are known and related to the patient while the patient is still in the office, a more accurate financial arrangement can be made with the patient, limiting the number of reconsiderations or appeals.

Here are The Trio of Guides which focus on:

• Procedure code bundling, the systematic combining of distinct dental procedures by insurance carriers that results in a reduced benefit for the patient/beneficiary.

• Down-coding, a practice of insurance carriers in which the procedure code has been changed to a less complex and/or lower cost procedure than was reported except where delineated in contract agreements.

• A least expensive alternative treatment clause, more commonly known as the LEAT clause, a type of cost-containment measure used by many insurance carriers when there are multiple viable options of treatment available for a specific condition, and the plan will only pay for the least expensive treatment alternative.

Estimating a patient’s portion is one of the most useful tools available to dentists. By estimating a patient’s portion prior to treatment, it allows more efficient treatment planning for both the provider and patient. Through the estimation of a patient’s portion, you can collect copay and deductibles on the date of service to minimise the chance of having uncollected balances and fees meanwhile the patient can plan accordingly and decide whether they can afford the treatment or not. This will reduce your outstanding account receivables and increase overall office collection.

As the end of the year approaches, most insurance plans get ready to reset the patients’ early maximum for the start of a new year. With this, it’s highly recommended to urge your patients to use up their remaining maximums as anything left over at the start of a new year will be rendered null and void as the maximum refreshes. To inform your patients of their maximum being reset, is it advised to send out a letter explaining now is a good time to exhaust your maximum. Along with the letter, it is also wise to call them with a list of their unscheduled treatments and encourage them to schedule their appointment. In this situation, the patient wins due to having more services done without affecting their new yearly max and the dental office has a chance at a boost in collection.

Every successful treatment plan begins with patient education. Properly educating and consulting with your patients is the first step in owning a successful dental practice. As Dental health is often regarded as “secondary” to medical health it is often overlooked by patients unaware of what damages an unmaintained mouth can cause. Well educated patients are more likely to seek treatment, schedule routine appointments with your practice, pay for additional procedures and are less likely to neglect treatment and view it as unnecessary. To have a well-educated clientele, the dental billing team and the dental team must work in conjunction. Where the dental team explains why the treatment is important, the billing team should be able to elaborate and justify its cost.

With the rising costs of personal protective equipment (PPE) due to supply shortages from the COVID-19 pandemic, maintaining a dental clinic has never been more costly. In an attempt to alleviate the spending on PPE the ADA has released a statement on third-party payer reimbursement for costs associated with increased standards for personal protective equipment. The ADA recommends reporting any spending on PPE under the code D1999 as a temporary solution to receive reimbursement for spending on PPE, something to keep in mind is that D1999 should be reported via a per-visit basis.