Avoid the Dental Tug-of-War

When a dental patient comes in for a perio maintenance visit, can you bill the insurance company for a regular cleaning?  How about when a patient receives a comprehensive exam, can you bill the service as a regular exam if the patient has exceeded frequency limits?

tug of war

These are common questions faced by dental teams, who are often caught in the tug-of-war between helping the patient maximize insurance benefits and documenting services appropriately.  Despite the desire to help patients, dental teams must always remember this fundamental concept: you have to bill the actual services that were provided.

This is sometimes difficult for patients to understand, especially if at a prior dental practice services were billed according to what maximized insurance benefits, not based on the actual services provided.  How then can you help the patient?

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First, make sure the patient understands the value of the service provided.  Patients often do not know the difference between a regular cleaning and maintenance visits that occur three to four times per year following treatment for gum disease.  Make sure the clinical team explains the purpose of the visit in plain English.  Avoid using terms such as “perio” or “prophy” or “deep pockets,” which only confuse patients further.  When patients understand the purpose of the visit, they assign greater value to the service.

Finally, explain to patients that you have to follow regulations that require billing for the actual service performed.  If patients are still upset, for example, that their exam is not covered due to frequency limits, encourage them to contact their human resources department and discuss the dental insurance contract.  Employee input can help shape future dental insurance provisions.

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Keep in mind that patient complaints about how services are billed have roots in other areas.  By ensuring that patients understand the value of their dental treatment and that they can have a voice in their dental plan construction, you greatly minimize getting caught in future tug-of-wars.

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