Orthodontic billing is one of the things that gets questioned all the time and in all truth, it probably deserves its own book. There are a number of reasons for the confusion that crops up between providers and insurance personnel whenever orthodontics comes into the picture. However, it’s just tough to make nifty catch-phrases over something that should be simple and relatively mundane. As we talk about some of these items remember that we are coming to you from an insurance adjusters point of view.
How Does Insurance View Orthodontics?
Let’s start with the insurance side of the coin. For an insurance company, orthodontics can be a big pain in the you know what. We have multiple providers supplying multiple types of services and billing for them in a myriad of billing styles. Some bill all up front. Some providers charge their patients a certain amount based on what their insurance will pay. Some providers have adjustable payment plans to allow patients to gradually pay for services over the years. All of these options and more make orthodontics billing more complicated than it should be.
From the insurance side, orthodontic benefits are strictly limited. Almost every plan we’ve ever seen has a maximum lifetime benefit. Note that there ARE exceptions to this rule, but an open-ended orthodontics maximum is an extremely rich benefit and is definitely being seen less and less these days. These benefits are usually applied to the individual patient, but may also apply to the entire family in some cases. For example, little Susie Jones who has a $1,000 lifetime maximum benefit for orthodontics goes to an Orthodontist and has $1,500 worth of work performed. The insurance company pays out based on their coverage level – usually 50 percent or 60 percent, which would make the payment in this situation $750 or $900 respectively. If Susie needs an additional $1,000 worth of work, she will only receive $250 or $100 – again dependent on coverage level. If the $1,000 orthodontic lifetime maximum applies to her entire family, then there will be NO other payments for any other members of her family. This is the starting point of view for insurance companies and different companies have different payment philosophies based on this starting point.
How Does Insurance Pay Orthodontics?
Some companies are just tired of dealing with orthodontics. They acknowledge that there is a strict limit put on orthodontic benefits, so they don’t even bother messing with it. They’re doing this because somebody somewhere made the decision that it costs more to try and review these claims than that review would be worth. Some companies take the opposite approach, since orthodontics can be such a big-ticket item. They’re going to require you to submit a logical, well-thought-out plan documenting every step of the process in that patient’s treatment. Then there’s another approach still in which the insurance company tries to control these treatments to ensure that the patient is really getting his money’s worth out of his orthodontic treatments. An excellent indicator of this is some kind of limitation on orthodontics dates-of-service. For example, a provider can submit an adjustment for little Susie dated April 27, 2011 and then another on May 2, 2011. Most companies will simply pay each of those without comment – their rules are set up to allow treatment once a month. In the real world though, is it really doing Susie any good to show up for two adjustments within a week of each other? Granted there are times where situations come up that this is necessary. We’re simply talking about the general rule, here. So there are some companies that will deny one of those adjustments since they consider them as not really being beneficial to the patient.
To make matters worse, many companies combine approaches on orthodontics. Some subscriber groups may have requested additional orthodontics scrutiny in an attempt to lower their premiums. Different departments within the same insurance company may have different rules. Some states may have different laws that make added scrutiny tougher or easier. All of these things combine to make a big swamp out of the process in which a lot of providers get lost.
When You Are WAY Too Consistent
Another scenario we see is that a provider submits the exact same way every single time. It’s statistically impossible for every patient an Orthodontist sees to get the exact same treatment. Now we know what’s happened. The provider found a ‘sweet spot’ – a set of claims that he KNOWS will work. And so he just uses them as a template every single time. There is not a lot we can say about this, other than it does put us on our guard. Also, it only benefits you as long as your treatment plans fall beneath that threshold. By not taking the time to learn and understand the true process, you’re simply handicapping yourself in those situations where you could be legitimately charging more and receiving higher reimbursements.
Not Quite the Final Word
This is probably a good place to take a break. We go into specific strategies in our e-book Dental Claims Help included in our Dental Insurance Course which will enable providers to start reading between the lines when it comes to insurance benefits and rules. Those can be extremely helpful in this area. You have to start by watching what you send out and learning from what comes back in (reading your Explanation of Benefits, talks with company representatives, etc.). Note differences in payments, denial codes, speed of payment, etc. You should already be working on baselines so that you know ‘normal’ processing times for the different companies. Watch how different companies handle similar claims in different ways. Watching and learning from all these things will teach you a lot about the different approaches to orthodontics.