James Anderson

Many dental offices, when they begun billing medical carriers, struggle with the difference between preauthorization and predetermination. In the dental field we are very familiar with predeterminations. We send them to patient’s plans to determine a more accurate cost of treatment on expensive dental procedures and treatment plans. We usually receive back a form letting us know, to the dollar, what an insurance plan will cover should the claim be processed successfully.
Treatment planning is a common struggle with dental offices that are new to medical billing. Understanding the coinsurance while factoring in the deductible and out of pocket maximum can seem like a foreign language to the most seasoned dental biller. It is also often hard to become accustomed to the fact that reimbursement will not suddenly stop at a specific dollar mark. The majority of medical plans have a lifetime maximum of $1 million or more – something that the average patient will usually not exceed.
Medical insurances often utilize preauthorization review for procedures that are over a certain amount or require extensive hospitalization or unconventional medical. A preauthorization is a review of clinical documentation to establish that a patient meets medical necessity to have the procedures performed under the rules of the health plan. The care management team is strictly looking at whether a patient meets the clinical criteria to need the proposed procedures. It does not provide any type of financial coverage data for the patient. Services will be subject to the deductible, out of pocket maximum and applicable coinsurance. Preauthorization needs are dictated by the patient’s policy and should be submitted when required.
A predetermination is more closely related to what we in dentistry are familiar with. A predetermination is a request to determine what a patient’s responsibility will be based on current deductible, out of pocket and coinsurance information. This type of review can be requested regardless of the plan’s protocol on preauthorization. This review will not look at the clinical documentation of medical necessity and the clinical information would be reviewed when the claim is submitted.
It is always important to check with the patient’s health plan if preauthorization is needed. Often times claims are denied because due diligence wasn’t performed before procedures were completed. While medical plans are more globally encompassing in terms of what is “covered” they do still have their own exclusions and rules that patients should be aware of. Make sure to educate your patients as much as possible in regards to their coverage to avoid angry billing errors later on down the line.
 

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