Experts share answers to seven common questions practices may have about medical billing.
Are you considering billing medical insurance but aren’t sure where to start? Do you understand the difference between in-network and out-of-network options? Are you wondering if the procedures you provide will be covered by medical insurance? This article offers answers to these questions and more.
Do I have to be a participating provider or sign a contract to bill medical insurance?
Medical insurance coverage varies or is restricted if you are a non-participating provider with certain types of plans. For example, Exclusive Provider Organizations (EPO) plans generally have no benefits for out-of-network providers except in the case of an emergency. On the contrary, Preferred Provider Organization (PPO) plans have both in-network and out-of-network benefits. Patients with these plan types can choose to see any provider but will likely have a higher out-of-pocket cost if they see a non-participating provider. The great news is PPO plans are still the most popular plans in the country, making up approximately 46 percent of all private insurance plans.
The key is to look at your patient’s insurance card. If your patient presents one for an EPO plan and you are out of network, it’s safe to tell them that their insurance does not offer coverage at your practice. If they have a PPO plan, you know that coverage is likely, and you can proceed to the next step.
These are limited examples, as there are four major private insurance plans and numerous state and federal plans.
EXPERT TIP: I don’t recommend that new practices contract with medical insurance for the first six months. This time allows you to see what coverage is available in your area and if participating would be beneficial.
How do I handle high deductibles?
Deductibles are an unavoidable part of billing medical insurance. The deductible is the amount a patient must pay out of pocket for covered services before the insurance company will contribute. Medical insurance generally has a higher deductible and nearly limitless benefit maximums. In contrast, dental insurance typically has a lower deductible but limited benefit maximums. It is essential to realize that in most cases patients are choosing their medical insurance plans. They are aware of their deductible and likely chose a higher deductible plan for the lower premium. That said, deductibles aren’t as high as many believe. According to the Kaiser Family Foundation (KFF), the 2020 average deductible for individual, employer-provided coverage was $1,644. That means that if your patient needs medically covered services exceeding their deductible amount, they would still receive benefits. If your patient needs $5,000 worth of medically covered services and has a deductible of $1,644 but has not satisfied any of the deductible for this policy year, your patient would pay the first $1,644 of treatment, and then medical insurance would contribute their percentage, based on their allowed amount. In this example, billing medical insurance could easily save your patient over 3,000. In contrast, if your patient has a high deductible plan, with a deductible of $5,000, the patient’s $5,000 treatment would be entirely applied to the deductible, and no benefits would be paid. However, the patient’s deductible is now satisfied for future medical services. If you were this patient, would you rather pay $5,000 for dental treatment or pay $5,000 for dental treatment and have your deductible satisfied?
EXPERT TIP: You will know the patients’ deductible and coverage before you present estimates if you complete a Verification of Benefit (VOB). This is why the VOB is essential. If the patient’s treatment plan is minimal and their policy has a high deductible, you may not want to bill medical insurance in this case.
What is credentialing, and why is it necessary?
Credentialing is the formal process in which a provider is registered and approved to bill specific insurance plans. Ultimately, you have to prove you are a qualified health care provider and register to submit medical claims to each payor. Credentialing is necessary for two reasons. First, to ensure that patients receive quality health care services from trained and qualified providers. The second is to acknowledge the provider and the details of the practice so that claims can be processed and third-party payments can be made. If you are not credentialed correctly, you will not be successful in billing medical insurance. In fact, it is the single most crucial step in getting started. You can do your own credentialing, or you can hire a professional. The process will vary from payor to payor but will include updating your profile with CAQH (Council for Affordable Quality Healthcare) and Availity and verifying your business information with your state’s Secretary of State. This process can be tedious and time-consuming, but most importantly, if there are any inaccuracies, your profile will not be created correctly, and your claims may be denied.
EXPERT TIP: Type 2, or organizational NPIs, are nearly always required for billing medical insurance. I strongly recommend you request your type 2 NPI right away if you don’t already have one. This will make the credentialing process much more efficient.
What dental procedures can be billed to medical insurance?
If you can prove medical necessity, every procedure in dentistry can be billed to medical insurance. It’s not about what you are doing; it’s about why you are doing it. So, the first question you should ask is: Is the procedure medically necessary? Can you prove that either the health of the oral cavity affects the rest of the body or that a health condition or medication affects the oral cavity? Here are a few examples. Acid reflux — if the patient has acid erosion of the teeth and has reflux, we can tie the health condition (acid reflux) to the oral cavity so the treatment needed to restore the teeth would be medically necessary. Periodontal disease — if the patient has active periodontitis, we know that the rest of the body is being affected. What if the patient also has a heart condition, is pregnant, or is diabetic? You can prove that periodontal disease affects the oral cavity and can also aggravate or complicate existing health conditions. The periodontal treatment would be considered medically necessary. The list here goes on and on. To learn more about what procedures can be billed to medical insurance, watch our free webinar, The Top 10 Medical Billing Questions.
EXPERT TIP: Even when you prove medical necessity, the payor and plan can still have exclusions for specific procedures. The VOB should be done for each procedure code within the treatment you have planned so you can accurately estimate coverage.
Does medical insurance always require pre-authorization?
Pre-authorization requirements are set by the individual payors and can vary. However, on most procedures over $500, pre-authorization is required. Pre-authorizations are a critical step and are not optional. If a plan has a pre-auth requirement and you complete treatment before receiving the pre-authorization, your claim will likely be denied. This step must happen PRE-treatment. In medical billing, the date of service (DOS) is the date you complete the treatment in its entirety. For example, if you are ordering a sleep appliance for a patient, you can scan or impress and even order the appliance from the lab without the pre-authorization. Just don’t deliver it until you have that pre-authorization number in hand. Pre-authorizations are when you must prove medical necessity. This is when you send all of your “evidence” or supporting documentation to the insurance company to show why this procedure is medically necessary and should be covered. Most offices, and even patients, find comfort in knowing there is an approved pre-authorization on file, as it will increase the probability and speed at which your claims are paid. It is essential to understand that pre-authorizations are not a guarantee of payment and do not provide approved amounts or fees. They will state that the requested services met their coverage guidelines and have been authorized. This will not explain what amount they will allow or pay. Pre-authorizations take approximately two weeks to process and consist of a letter or form specific to the payor and all of your supporting documentation.
EXPERT TIP: Pre-authorizations are only valid for a certain period of time, typically 90 days. Pay close attention to expiration dates, as a DOS outside the pre-authorization window will be denied.
Can I calculate an accurate patient portion?
Accurately estimating patient portions when you are an out-of-network provider is a challenge. While we do our best to help our clients with this process, it takes time and experience with your local payors. Consider this: you will likely have 5–6 major payors in your area. The first time you bill a specific procedure to each of these plans you will not know their allowable. This makes it difficult to estimate what portion the insurance will contribute. However, after the first claims are processed, you will know, with minimal margin of error, what that plan will allow. Moving forward, you can use this experience, and the data you collect, to help estimate contributions more accurately.
There is excellent news that will help alleviate this problem. As of July 2022, insurance companies are required, under the Transparency in Coverage Rule, to publish allowable fees for both in-network and out-of-network providers. Payors are slow to comply, but this is a start in the right direction. Several additional rules go into effect in January 2023. These rules are meant to make health care costs transparent. For now, these allowable and fee schedules are only available to third-party companies. Our clients will have access to this information as soon as it’s available.
EXPERT TIP: If you are new to medical billing and struggling to present estimates to patients, consider starting with courtesy medical billing. This means the patient still pays 100 percent of treatment costs, and you bill medical insurance as a courtesy. Any amount covered by the insurance will then be reimbursed to the patient. You only need to do this for a short time before collecting enough data to estimate insurance contributions accurately.
Where do I start?
If you are ready to add medical billing to your practice and help more patients access the care they need, you need to answer a few questions. Are you planning to do this on your own or enlist the help of experts? Is your team adequately trained, or will they need additional training and support? What top five procedures would most benefit your patients if they were covered by medical insurance? If you need help answering these questions, we offer free expert calls. Click here to schedule a call. In the meantime, there are a few things you can do now to make the process smoother.
- Start collecting copies of medical insurance cards for all patients. Ensure you get a copy of the front and back of each card. This will be essential when credentialing, enrolling in electronic claims and portals, and determining which plans you will be billing.
- Obtain a type 2, organizational NPI if you don’t already have one.
- Start collecting your paperwork for credentialing. You will need the following:
- Your ADA username and password
- Access to your NPI information
- Ensure that you have an authorized official on your NPI account
- W-9 Form
- Malpractice insurance with COI/Declaration page
- Copy of DEA license
While medical billing can be overwhelming, the potential to help patients access the care that they need is more than worth it. Devdent offers different levels of support and training to meet the needs of any practice. Whether you need minimal help getting started or need our advanced support program, we will help you achieve success.
Devdent offers credentialing services, education courses, and medical billing software and support. Imagn Billing software includes dental-to-medical cross coding, electronic claim submission, real-time case status updates, and more. Let the Experts at Devdent help you better help your patients.
Visit https://campaign.dentrix.com/imagn for more information or to schedule a call with one of our experts.
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By Crystal May, COO and co-founder of Devdent and Imagn Billing
Crystal May is the co-founder and COO of Devdent. She is dedicated to helping dental practices be successful in dental sleep medicine and medical billing. She has over 17 years of medical billing experience, 15 years with an emphasis on dentistry, and 10 years on airway and sleep. Crystal is a leading educator and has presented at hundreds of events for major corporations and organizations. She owns and manages multiple dental practices, holds multiple US and international patents, has developed several software products specifically designed for dental offices, and has started companies that help practices with the successful implementation of dental sleep medicine and medical billing. Crystal’s mission is to educate every dentist in the country about their opportunity and obligation to help identify sleep disorders in their patients.