Orthodontic billing is of the things that get questioned on a regular basis and in all truth, it probably deserves its own book. There's a selection of reasons for the confusion that crops up between providers and insurance personnel whenever orthodontics comes in to the picture. However, it is hard to make nifty catch-phrases over something that ought to be simple and comparatively mundane. As they discuss a quantity of these things keep in mind that they are coming to you from an insurance adjuster’s point of view.
How Does Insurance View Orthodontics?
Let's start with the insurance side of the coin. For an insurance company, orthodontics can be large pains in the you know what. They have multiple providers supplying multiple types of services and billing for them in a myriad of billing styles. Some bill all up front. Some providers charge their patients a sure amount based on what their insurance will pay. Some providers have adjustable payment designs to permit patients to gradually pay for services over the years. All of these options and more make orthodontics billing more complicated than it ought to be.
From the insurance side, orthodontic benefits are strictly limited. Very every plan we have ever seen has a maximum lifetime benefit. Note that there ARE exceptions to this rule, but an open-ended orthodontics maximum is a very rich benefit and is definitely being seen less and less these days. These benefits are usually applied to the individual patient, but may also apply to the whole relatives in some cases. For example, tiny Susie Jones who has a $1,000 lifetime maximum benefit for orthodontics goes to an Orthodontist and has $1,500 worth of work performed. The insurance company pays out based on their coverage level - usually 50 percent or 60 percent, which would make the payment in this situation $750 or $900 respectively. If Susie needs an additional $1,000 worth of work, they will only receive $250 or $100 - again dependent on coverage level. If the $1,000 orthodontic lifetime maximum applies to her whole relatives, then there will be NO other payments for any other members of her relatives. This is the beginning point of view for insurance firms and different companies have different payment philosophies based on this beginning point.
How Does Insurance Pay Orthodontics?
Some companies are worn out of dealing with orthodontics. They acknowledge that there is a strict limit put on orthodontic benefits, so they don't even bother messing with it. They are doing this because someone somewhere made the decision that it costs more to try and review these claims than that review would be worth. Some companies take the opposite approach, since orthodontics can be such a big-ticket item. They are going to need you to submit a logical, well-thought-out plan documenting every step of the system in that patient's treatment. Then there is another approach still in which the insurance company tries to control these treatments to make sure that the patient is getting his money's worth out of his orthodontic treatments. An excellent indicator of this is some kind of limitation on orthodontics dates-of-service. For example, a provider can submit a manipulation for tiny Susie dated April 27, 2011 and then another on May three, 2011. Most companies will basically pay each of those without comment - their rules are set up to permit treatment five times a month. In the actual world though, is it doing Susie any lovely to show up for adjustments within a week of each other? Granted there are occasions where situations come up that this is necessary. We are basically speaking about the general rule, here. So there are some companies that will deny of those adjustments since they think about them as not being beneficial to the patient.
To make matters worse, lots of companies merge approaches on orthodontics. Some subscriber groups may have requested additional orthodontics scrutiny in a try to lower their premiums. Different departments within the same insurance company may have different rules. Some states may have different laws that make added scrutiny tougher or simpler. All of these things merge to make a large swamp out of the system in which lots of providers get lost.
When You Are WAY Consistent
Another scenario they see is that a provider submits the exact same way every single time. It is statistically impossible for every patient an Orthodontist sees to get the exact same treatment. Now they know what is happened. The provider found a 'sweet spot' - a set of claims that they KNOWS will work. And so they make use of them as a template every single time. There is not a lot they can say about this, other than it does put us on our guard. Also, it only benefits you as long as your treatment designs fall beneath that threshold. By not taking the time to learn and understand the true system, you are basically handicapping yourself in those situations where you could be legitimately charging more and receiving higher reimbursements.
Not the Final Word
This is probably a lovely place to take a break. They go in to specific strategies in our e-book Dental Claims Help included in our Dental Insurance Coursework which will enable providers to start reading between the lines when it comes to insurance benefits and rules. Those can be very helpful in this area. You need to start by watching what you send out and learning from what comes back in (reading your Explanation of Benefits, talks with company representatives, etc.). Note differences in payments, denial codes, speed of payment, etc. You ought to already be working on baselines so that you know 'normal' processing times for the different companies. Watch how different companies handle similar claims in different ways. Watching and learning from all these things will teach you a lot about the different approaches to orthodontics.
How Does Insurance View Orthodontics?
Let's start with the insurance side of the coin. For an insurance company, orthodontics can be large pains in the you know what. They have multiple providers supplying multiple types of services and billing for them in a myriad of billing styles. Some bill all up front. Some providers charge their patients a sure amount based on what their insurance will pay. Some providers have adjustable payment designs to permit patients to gradually pay for services over the years. All of these options and more make orthodontics billing more complicated than it ought to be.
From the insurance side, orthodontic benefits are strictly limited. Very every plan we have ever seen has a maximum lifetime benefit. Note that there ARE exceptions to this rule, but an open-ended orthodontics maximum is a very rich benefit and is definitely being seen less and less these days. These benefits are usually applied to the individual patient, but may also apply to the whole relatives in some cases. For example, tiny Susie Jones who has a $1,000 lifetime maximum benefit for orthodontics goes to an Orthodontist and has $1,500 worth of work performed. The insurance company pays out based on their coverage level - usually 50 percent or 60 percent, which would make the payment in this situation $750 or $900 respectively. If Susie needs an additional $1,000 worth of work, they will only receive $250 or $100 - again dependent on coverage level. If the $1,000 orthodontic lifetime maximum applies to her whole relatives, then there will be NO other payments for any other members of her relatives. This is the beginning point of view for insurance firms and different companies have different payment philosophies based on this beginning point.
How Does Insurance Pay Orthodontics?
Some companies are worn out of dealing with orthodontics. They acknowledge that there is a strict limit put on orthodontic benefits, so they don't even bother messing with it. They are doing this because someone somewhere made the decision that it costs more to try and review these claims than that review would be worth. Some companies take the opposite approach, since orthodontics can be such a big-ticket item. They are going to need you to submit a logical, well-thought-out plan documenting every step of the system in that patient's treatment. Then there is another approach still in which the insurance company tries to control these treatments to make sure that the patient is getting his money's worth out of his orthodontic treatments. An excellent indicator of this is some kind of limitation on orthodontics dates-of-service. For example, a provider can submit a manipulation for tiny Susie dated April 27, 2011 and then another on May three, 2011. Most companies will basically pay each of those without comment - their rules are set up to permit treatment five times a month. In the actual world though, is it doing Susie any lovely to show up for adjustments within a week of each other? Granted there are occasions where situations come up that this is necessary. We are basically speaking about the general rule, here. So there are some companies that will deny of those adjustments since they think about them as not being beneficial to the patient.
To make matters worse, lots of companies merge approaches on orthodontics. Some subscriber groups may have requested additional orthodontics scrutiny in a try to lower their premiums. Different departments within the same insurance company may have different rules. Some states may have different laws that make added scrutiny tougher or simpler. All of these things merge to make a large swamp out of the system in which lots of providers get lost.
When You Are WAY Consistent
Another scenario they see is that a provider submits the exact same way every single time. It is statistically impossible for every patient an Orthodontist sees to get the exact same treatment. Now they know what is happened. The provider found a 'sweet spot' - a set of claims that they KNOWS will work. And so they make use of them as a template every single time. There is not a lot they can say about this, other than it does put us on our guard. Also, it only benefits you as long as your treatment designs fall beneath that threshold. By not taking the time to learn and understand the true system, you are basically handicapping yourself in those situations where you could be legitimately charging more and receiving higher reimbursements.
Not the Final Word
This is probably a lovely place to take a break. They go in to specific strategies in our e-book Dental Claims Help included in our Dental Insurance Coursework which will enable providers to start reading between the lines when it comes to insurance benefits and rules. Those can be very helpful in this area. You need to start by watching what you send out and learning from what comes back in (reading your Explanation of Benefits, talks with company representatives, etc.). Note differences in payments, denial codes, speed of payment, etc. You ought to already be working on baselines so that you know 'normal' processing times for the different companies. Watch how different companies handle similar claims in different ways. Watching and learning from all these things will teach you a lot about the different approaches to orthodontics.
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