You’ve begun accepting medical insurances and submitting claims. Things are going well until you have a patient who has been referred to you. Their treatment is clearly medically necessary, their dentition was affected by recent oral cancer treatment and surgery. The pre-authorization for services has been approved through their medical carrier but a medical insurance breakdown of benefits reveals a very high out-of-network deductible. The patient cannot afford treatment without being able to use their in-network benefits which offer a much lower deductible that they have already met due to other medical treatments.
A gap waiver may be your solution. Many practices do not want to sign participating provider contracts because it can reduce their reimbursement and leave them vulnerable to bundling of procedures and other unpleasant side effects. Maybe they just don’t want the additional paperwork of enrollment and credentialing. A gap waiver is a request, on a case by case basis, that a specified services you will be performing be treated as in-network.
Gap waivers should be requested either at time of preauthorization or, if preauthorization is not required, then in advance of any procedures performed. They should be requested in writing as part of the preauthorization or, when preauthorization is not necessary, they should be submitted in letter format with a listing of the procedures seeking to be performed.
If approved a gap waiver will allow your patient to utilize their in-network benefits despite your out-of-network status. This can increase case acceptance and entice patients to schedule treatment. You should educate yourself on the average in-network reimbursement for the carrier you are submitting the request for to be sure they are fees your practice can accept. After the gap waiver is approved you will need to know the patient’s in-network deductible and out of pocket to correctly estimate their patient portion. Gap waivers can be a great tool in the world of dental medical billing.
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