Dental insurance policies may have an alternate benefits clause, which, according to Perio-Implant Advisory, is “a provision that helps determine how payment will be made when there are several ‘clinically accepted’ dental services that can satisfactorily correct the dental dentition.” It is occasionally called the Least Expensive Alternative Treatment (LEAT) clause because the policy would cover the least expensive treatment option, but patients could still choose the pricier procedure. With the pricier option, they would be covered at the rate of the cheaper treatment, but pay more out-of-pocket based on the price difference of the fees established by the clinic.
Applying the Alternate Benefits Clause
The alternate benefits clause can apply to many services. The clause can include many types of procedures that would affect the patient’s overall bill. For instance, when patients need a restoration for their bicuspids and molars, the amalgam (silver) filling is cheaper than the composite or resin (white) filling. The clause usually covers fillings at the rate of the amalgam option, reducing the amount the dentist’s office is reimbursed and increasing the patient’s out-of-pocket copayment, if patients choose the resin fillings. If the patient needs crowns for their molars, the policy covers the all-metal crown as the alternate benefit instead of the all-porcelain (white) crowns and porcelain-covering base-metal crowns, both of which cost more than the all-metal crowns.
While the alternative treatment may work just as well as the more expensive treatment, the dentist may recommend the pricier option if it benefits the patient more, based on the clinical circumstances or the needs and desires of the patient. Sometimes, patients could benefit from the cheaper option. For instance, while resin composite fillings look more similar to the patient’s teeth than metal fillings, patients have to replace resin fillings more often because they last five to seven years (half the lifetime of an amalgam filling). Patients also must go through a longer process with a resin filling than a metal filling. Based on these comparisons and assuming that the patients are not allergic to the metals in the amalgam, patients could choose amalgam fillings for less out-of-pocket payments under the alternate benefits clause.
Dentists and patients should review the clause thoroughly and get a pre-estimate before proceeding with treatment. The clause can help direct patients to more affordable options. However, since dental conditions could differ between individual patients, some patients may have to choose the more expensive option.
If you struggle with alternative benefits clauses while verifying insurance, consider partnering with eAssist. Our Success Consultants will ensure any possible alternative benefits clauses are addressed when verifying insurance coverage. To learn more, schedule a consultation here.
