Week 7: Dental Insurance
This week you will be learning about dental insurance, which is one category commonly offered in most private insurance plans. Additional details about private insurance will be reviewed during week 12, so stay tuned for more information about this important topic!
Dental Insurance Terms
- Copayment/coinsurance: the percentage of the service fee that the insurance company pays
- Deductible: a set fee that the client pays before the insurance coverage takes place
- Annual Maximum Benefit: total dollar amount that the insurance company will pay out
- Coordination of Benefits: processing coverage under 2 insurance plans to minimize the cost out of pocket
- Primary Plan: the policy that gets processed first
- Secondary Plan: once a claim gets processed through the primary plan, any remaining amount not covered can be processed through the second up to a max of 100% of total expenses paid
- Assignment of Benefits Form: a consent form the client completes to allow clinics to receive payment directly from the insurance company
Test your knowledge:
Healthy Smiles
As learned in ADMN1030, the Ontario government offers supplementary programs to vulnerable populations in order to maintain and improve health status. One program most often utilized in dental offices is Healthy Smiles, which provides free dental care to children 17 years old and under who belong to low-income families. Types of dental care include preventative, routine, and emergency services.
Visit the province’s Healthy Smiles program website to learn more about this special dental benefit including qualifications for enrolment and locations of offices participating in this program. *Note: since offices are not required to enrol, some will not offer this benefit.
How Do Dental Offices Receive Payment?
Payment Options
Most common:
- Fee-For-Service:
- The dentist receives payment (either through the client or insurance company) for each service or procedure they provide.
- Assignment of Benefits:
- If a client has private insurance, they can complete an assignment of benefits form to allow the clinic to direct bill. This means that the client has to pay out of pocket only the portion of the visit not covered through insurance.
- Note: some clinics do not offer direct billing. In this case, the HOA may assist clients in completing manual claim forms, and process payment as an out of pocket expense.
Less common:
- Capitation:
- Employers contract a local dentist to provide dental care to a group of employees at a cost per capita.
- The dentist receives payment from the employer every month based on the number of clients treated.
As an HOA, consider what the advantages and disadvantages would be for either approach.
Dental Provisions
The Ontario Dental Association (ODA) creates a fee guide to highlight procedure codes and suggested reasonable fees. Dental offices are not restricted by these fees and many will charge at their discretion.
However, insurance companies use this guide to set coverage limitations/provisions.
Let’s explore some common insurance provisions below:
Dental Insurance Limitations/Provisions
- Treatment must be necessary: A client cannot receive treatment solely because they have coverage. Elective or cosmetic dental work is often excluded from dental plans. Clients must therefore pay for these services fully out of pocket.
- Only a dentist can recommend treatment: As previously learned in this course, the dentist holds legal responsibility for the clients and is the only provider who can recommend a treatment plan.
- Cost of treatment: The treatment option may not be the most cost-effective, and cannot be based on coverage details.
- Frequency: Clients are often limited to recall time frames. The most common provisions are 6 or 9 months. Important to remember when scheduling recall visits. Changing the date on a past appointment, receipt, or claim is fraud. If a client ever asks you to alter dates for coverage, you must decline.
- Alternate Benefit Clause: Insurance policies may reimburse a lower-cost option of treatment regardless of the service and fee that was performed.
- Open Space: For dentures, bridges, or implants to be covered, the natural tooth must have been extracted while the client was covered under the insurance policy. (Cannot wait to have a procedure done until they have insurance).
- Lagging Fee Guide: Insurance companies will use the ODA fee guide to set reasonable dental fees. Sometimes they will base their fees on previous fee guides rather than current fee guides. It depends on how frequently the policy gets updated.
Remember… unlike OHIP, all private insurance policies are different! Coverage amounts and provisions may differ depending on the policy.
Completing Insurance Forms
Depending on your office, you may be required to submit dental claims online through a secure network such as CDAnet. You may also be required to complete manual claim forms in the event your office does not direct bill, there is a power outage, or your client’s policy does not allow for direct billing. Regardless of the method, you will need to input the following information: client information, policy information, clinic/provider information, procedure code, tooth#, surfaces, and fees.
The standard dental claim form is available on the Canadian Dental Association website.
The ODA fee guide is available on the Ministry of Health website.
Insurance Practice
Case 1: Your client Bob visited your office on June 1, 2022. He had a complete oral exam from the general dentist for permanent dentition. Your dental office charges the same fees set out in the ODA guide.
Complete the dental claim portion below using the ODA fee guide as a resource.
Case 2: Your client Elise visited your office on July 10, 2022. The general dentist performed an amalgam restoration on the occlusal and distal surfaces of her maxillary right first bicuspid. Your dental office charges the same fees set out in the ODA guide.
Complete the dental claim portion below using the ODA fee guide as a resource.
Case 3: Your client Karanjot visited your office on September 18, 2022. He had 2 units of time for scaling. Your office charges the same fees set out in the ODA guide.
Complete the dental claim portion below using the ODA fee guide as a resource.
References
Baillargeon, S. (2008). Dental office administration. Thomson Nelson.
Canadian Dental Association. (n.d.). CDA standard dental claim forms. https://www.cda-adc.ca/en/services/cdanet/standard_dental_form.asp
Canadian Life & Health Insurance Association. (n.d.). A guide to the coordination of benefits [opens a PDF]. https://www.clhia.ca/web/CLHIA_LP4W_LND_Webstation.nsf/resources/Consumer+Brochures/$file/Brochure_Guide_To_CoOrdinationBenefits_ENG.pdf
Ministry of Health and Long-Term Care (2016). Healthy Smiles Ontario schedule of dental services and fees for dentist providers [opens a PDF]. https://www.health.gov.on.ca/en/pro/programs/dental/docs/HSO_Schedule_of_Dental_Services_and_Fees-Dentist_Providers_en.pdf
