6 Helpful Insurance Verification Tips

September 2023
Rob Linder
Admin/Record Keeping/Charting

At first glance, insurance verification is deceptively simple as it appears to be just confirming what insurance coverage the patient has. It’s actually much more than that. It’s a multi-step process that confirms the various details of the patient’s insurance coverage in order for claims to be submitted correctly and treatment to get paid. It’s an essential part of the billing process albeit one that tends to get neglected which often leads to denied claims and unhappy patients. In order to avoid that, here are six insurance verification tips to ensure the process runs smoothly. 


Insurance verification for every patient, every appointment 

You may be tempted to think that insurance verification is simply confirming a new patient’s coverage upon their initial visit but it’s actually a continuous process. Insurance coverage is constantly changing. There are several reasons for this such as a patient switching plans for financial reasons or changing employers. Because of this, never rely on an initial verification alone as the plan may not be valid the next time you see the patient. It’s essential to contact the insurance for every visit in order to confirm the coverage is still active. 


Confirm the annual maximum during insurance verification

When a patient has PPO coverage their plan most likely has an annual maximum benefit amount. This generally ranges from $1000-2000 and once it’s reached the insurance will no longer issue any payment until the new plan year. Not only is it essential to verify what the annual maximum is, but also how much of it has already been met. For instance, if a patient has an annual maximum of $2000 it may appear to be enough to cover the planned treatment, but, if they have already used $1750 it probably won’t. As the year progresses, this becomes more likely so it’s important always to clarify how much has already been used during the insurance verification process. 


Confirm the deductible during insurance verification 

In addition to an annual maximum, most PPO patients have a plan deductible. For dental insurance, it ranges from $25-100 so it’s generally reached early in the plan year. For medical plans, it’s much higher, averaging $1600. As dental and medical care continue to integrate it’s becoming more common for medical insurance to be billed. When completing insurance verification, it’s important to verify the deductible amount and whether or not it’s been already reached as it can easily match or exceed the treatment cost. 


Confirm frequency limits during insurance verification 

Most plans have frequency limits for numerous dental procedures from exams to crowns. When completing insurance verification, always check the frequency limits for the CDT codes you are planning to bill. For instance, restorations, such as D2740, often have a frequency limit of 5-10 years. Scaling and root planing, both D4341 and D4342, are covered once every 2 years. When it comes to exams and consults there’s a limited amount paid per year, usually no more than 2. It’s always best to check if there is a frequency limit for the procedures scheduled to confirm if they will be covered or not. 


Confirm the waiting period during insurance verification 

You may assume all treatment is covered immediately upon the plan's effective date but this is not always true. There are various insurance plans that apply a waiting period to certain treatments.  Some apply it to anything beyond exams and x-rays while others limit it to specialty treatment. It can be as short as 30 days and as long as 12 months, depending on the treatment involved. As such, during insurance verification, it’s always best to check if a waiting period applies.


Outsourcing insurance verification

It may seem like we’ve already reviewed a lot but it’s only the tip of the iceberg when it comes to insurance verification. For instance, we haven’t even touched on age limits, missing tooth clauses, and alternative benefit downgrades. If you’re feeling that there just isn’t enough time to verify insurance, consider outsourcing. At eAssist, the Success Consultants who use its platform take the time to ask all necessary questions when verifying coverage so that you will have peace of mind when the treatment is completed. There are multiple service options available and they start as low as $225 a month which can accommodate any office size.  

As you can see, insurance verification is an essential part of the dental billing process that shouldn’t be neglected. These six insurance verification tips will help ensure the process is completed thoroughly and correctly which will, in the long run, allow your dental billing to run smoothly and keep your patients happy.

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