In Part 1 and Part 2 of “Breakdown the Insurance Breakdown Form” we discussed the three reasons why accurate insurance breakdown forms are so important. We then began breaking down what each section of the breakdown forms means. Today we are going to get into the meat of the insurance breakdown form and discuss the preventative, basic and major services. 

To follow along you can get my free detailed insurance breakdown form at www.bonddentalconsulting.com/dental-freebies. 

• Percentages for Preventative, Basic, Major. The standard for most dental insurance companies and what usually automatically populates in your dental software is 100%, 80%, 50%. But nothing is ever quite standard with insurance companies. So always check! Then double check what this plan includes under preventative, basic, and major. For instance, some plans cover diagnostic x-rays under basic and some plans cover perio under major. Each plan is different so these small details are so important for accurate treatment estimates.

 Let’s get into the specific examples:

• Exams- how many are covered per year? Usually this coincides with prophys per year which we will discuss in a bit.

• FMX/PAN- typically these two codes are interchangeable. Especially for new patients and perio patients, you want to know how often this patient is eligible for a full set of x-rays or panoramic x-ray. I advise our dental offices to always take this type of x-ray on their new patients and if they have a recent history of this then you will either have to get it transferred from another dentist or let the patient know ahead of time that this will be an out of pocket expense. For your perio patients, I recommend to take this type of x-ray once every three years. For some that only have coverage once every 5 years, this may mean it will be out of pocket for them. This is information that both you and the patient will want to know ahead of time.

• BWX- These x-rays are typically taken once a year at a dental office. You want to know if this plan covers them at that frequency or I’ve seen companies only cover them once every two years. Sometimes it is once every 12 months to the day, so we need to make sure we have our appointments scheduled correctly or make the patient aware of their out of pocket expenses. 

• Prophy- This is what most of our patients come in for, right? Their dental cleaning. The last thing we want is to schedule our patient in for their second cleaning for the year and realize 30 days later that insurance did not pay because they cover prophys once every 6 months to the day, and we had them come in one day early. It hurts, trust me I know. This is why we ask this question. What is the frequency they can get their prophy during the year? Typically, as I said above, this coincides with their frequency allowed for exams.

• Perio Maintenance- This code is a free-for-all for all insurance companies. Some cover this at 100%, some at 80%, some not at all. We need to know what percentage this procedure is covered at for our perio patients. We also need to know how many they are allowed each year. Again, insurance doesn’t dictate the treatment we recommend. If they need four perio maintenances a year, then they need that. However, we need to know to collect for two of them and not wait to chase that money down after their appointment.

• SRP- It is important to know for scaling and root planing if we can do four quads in one day. Typically offices like to separate these out, but we have had patients ask if they can just get it done at the same time. I have also seen dental insurance policies making patients wait at least seven days between SRP visits. While clinically this makes no sense, it is part of their guidelines for that plan and something we need to know for our patients.

• COMPOSITE FILLINGS– We all know that amalgam is no longer the go-to material for restorations, yet dental insurance is still not up to date. A lot of times insurance companies will downgrade posterior teeth to amalgam fees and the patient is responsible for the difference. Again, this doesn’t mean we change our treatment recommendations, but we do let the patient know that their company downgrades their fees to the cost of a silver filling. We can then explain that our office does not place silver fillings, so there may be a difference in the fee we collect and the portion that is due once we get insurance back. I advise patients that this is usually $20-$50 a tooth. 

• CROWNS– speaking of downgrades, there are also insurance companies that downgrade posterior or any crown to another type of restoration. That is why it is important to note this question when asking about crowns specifically. We also want to know if crowns are paid on the prep or seat date, and if there is a replacement clause. While the typical replacement clause is five years, I have come across plans that have a ten year replacement clause on crowns. This means if a patient is in need of another crown before the ten years is up, then insurance will not cover it.

• GUARDS- if your office recommends custom guards for your patients then you want to know if this is a covered benefit. A lot of times it is an out of pocket expense for the patient, so we want to go over that full treatment plan with them from the beginning. Another thing to check is if guards are covered for bruxism or only after surgery. If there is 80% coverage via the fax back form, I would always make sure I am 100% confident that it is due to bruxism.

• ORTHO– lastly, if your office does adult orthodontics, then you want to get the coverage for adults specifically. On top of that, if you are in-network, you want to know if you can charge the difference between your contracted amount and the upgrade charge for clear aligners. I would also ask if they cover the cost for orthodontic retention as well. You need to know if performing orthodontic work for your patients is worth it financially for your office, especially with the costly lab fees. 

There you go! We were able to breakdown the insurance breakdown form. As you can see, there is a lot that goes into getting an accurate and detailed breakdown for your patients. Not only does this enhance your patient experience, enhance your collection rate, but it also enhances your knowledge every time you get a detailed breakdown. Don’t miss out on any of these vital questions and take the surprise out of your patient’s dental bills. Again to access my free detailed breakdown form to use for your office go to www.bonddentalconsulting.com/dental-freebies. If you are ready to outsource your dental billing needs to a dental expert, view our monthly packages at www.bonddentalconsulting.com/dental-billing.