Working with Patients on Dental Insurance Coverage Disputes

Dental health is an essential aspect of overall well-being, yet many people avoid dental visits due to cost concerns. Cost is cited as the number one reason individuals avoid the dentist. This financial burden is significant enough that almost one-third of Americans haven't visited a dentist since before the pandemic. Dental insurance can alleviate some of these costs, but only if patients understand how to use it effectively. Here is how dental practices can assist patients in navigating insurance coverage disputes and help patients make the most of their dental insurance.

The Cost Barrier in Dental Care

The high cost of dental care is a major deterrent for many individuals. Unlike medical insurance, dental insurance often has lower coverage limits and more out-of-pocket expenses. Patients may find themselves facing substantial bills, even for routine procedures. Fifty-nine percent of individuals have avoided dental treatment due to cost; in fact, this was the top reason for treatment delay.

Dental practices can alleviate some of this burden. That’s not to say that practices should engage in steep price cutting.

In fact, heavily discounting dental services can have an opposite effect in facilitating care, leading to;

• unrealistic patient expectations regarding future pricing
• a lower perception of care quality
• an unsustainable business model
• damage to professional reputation within the dental community
• a need to rely on lower quality tools and materials or less effective treatment paths

Price cutting is never the answer and frequently yields poor results for the patient. Instead of engaging in a race to the bottom on price, practices should help guide patients through the resources they already have available to cover their care–their dental insurance.

Unfortunately, the complexity of dental insurance policies, with their various terms and conditions, can be overwhelming for patients. Many policies have annual maximums and specific exclusions that can complicate coverage. As dental professionals, it's crucial to understand why these claims are denied to help guide patients and keep them on track.

Why Dental Claims Get Denied

Dental claims denials are a common frustration for both dental practices and patients alike. Unfortunately, they're also a fact of life. As an example, about every general practitioner has had a claim for periodontal scaling and root planing (SRP) procedures denied.

These procedures, which are crucial for treating gum disease, are often deemed by insurers as not medically necessary or exceeding the patient's coverage limitations. Despite being recommended by dental professionals for patients with periodontal disease, insurers may dispute the necessity of these treatments. However, periodontal scaling and root planing denials are just one aspect of a broader issue with dental claims.

Other common reasons for claim denials include:

Pre-authorization	Coding Errors	Missing Information	Policy Limitations	Non-covered Services
Failure to obtain pre-authorization for certain procedures can lead to claim denials, leaving patients responsible for the full cost.	Claims denials may also occur as a result of incorrectly coding procedures in forms.	Incomplete claim forms or documentation can cause claim denials, emphasizing the need for thorough and accurate submission.	Coverage limitations such as annual maximums and waiting periods can lead to denied or partially covered claims, requiring patients to cover additional expenses.	Some procedures may not be covered by insurance at all.

Navigating the complexities of dental insurance and claim denials can be challenging for both dental practices and patients. To mitigate the risk of denials, dental practices should stay informed about insurance guidelines, communicate effectively with patients about coverage limitations, and advocate on behalf of patients when disputes arise.

Helping Patients Navigate Insurance Coverage Disputes

Having a claim denied is likely to cause patients to avoid treatment or stop care that’s already in process. Your dental practice team can help patients avoid these issues and make the most out of their coverage by taking a few steps.

• Educate patients on their plans: The first step in helping patients is education. Dental practices should take the time to explain the details of patients' insurance plans, including covered services, annual maximums, deductibles, and co-payments. Providing written materials or online resources that break down these aspects can be incredibly beneficial.
• Provide pre-authorization assistance: Some dental procedures require pre-authorization from the insurance company. Assisting patients with the pre-authorization process can prevent delays and denials of coverage.
• Estimate costs upfront: Offering patients an estimate of their out-of-pocket costs before any procedure helps manage their financial expectations. This transparency can build trust and allow patients to plan financially for their dental care.
• Appeal denied claims: If a dental practice has valid reasons to believe that a denied claim should be covered, they can submit an appeal to the insurance company, providing additional documentation and justification to support their case.
• Consider flexible payment plans: Flexible payment plans can make dental care more accessible to patients facing high out-of-pocket costs. By offering installment options or financing through third-party providers, dental practices can help patients manage their expenses over time. This flexibility reduces the immediate financial burden and encourages patients to proceed with necessary treatments.

Dental practices play a critical role in supporting patients through insurance coverage disputes. By providing clear information, assisting with administrative tasks, and offering financial planning options, dental offices can help alleviate the stress and confusion associated with dental insurance. This support not only improves patient satisfaction but also encourages regular dental visits, enhancing overall dental health.