There is some seriously mixed information running around town about primary and secondary insurances and once and for all, we want to be the resource that helps bring clarity to this confusing topic.
What if my favorite unicorn patient walks in with two dental insurances?
Do I wave the white flag of surrender?
Do I tell them the age-old phrase "We are just a 3rd party, how your insurance works is between you and your insurance company, we are filing this claim as a courtesy... figure it out." Do I tell them, we don't process secondary claims?
No ma'am/sir, and we can teach you exactly how to process dual insurance.
Personally, it's our opinion dental offices across the nation have become accustomed to these phrases, quotes, lines, and what have you because we simply just do not know how to process dual insurances. So, here is a bunch of free carrots for you today. Oh, and if we beg please don't be one of those "I know everything" people with the hopes of proving it wrong, we went to the experts like the ADA, Delta Dental, and the National Association of Insurance Commissioners for this information. We worked hard to put this together and want to bring you all the good stuff we possibly can. Let's be here to encourage and build each other, not break down and criticize :)
Alright, let's do this...
When a patient has two dental insurances, this is called "dual coverage." This does not mean "double" the coverage (contrary to popular belief). However, it may reduce out-of-pocket expenses depending on treatment diagnosed by a dentist.
Dual coverage works the same way whether a patient is covered by two dental plans that are the same or two entirely different dental insurance companies. You will notice many insurance companies do in fact work together to coordinate your patient's benefits.
So, which plan pays first?? The chicken, or the egg? Haha... We are only kidding...
For real though, the dental insurance plans set forth rules to determine which plan pays first, ("primary") and which plan pays afterward ("secondary"). The general rule is that the plan that covers the patient as an enrollee is the primary plan and the plan which covers the patient as a dependent is the secondary plan.
For a child's coverage, generally, the primary insurance company is determined by the birthday rule (i.e., coverage of the parent whose birthday —month and day, not year — (SAY IT LOUDER FOR THE PEOPLE IN THE BACK) comes first in the year YOU ARE CURRENTLY IN is considered to be your children's primary coverage). A divorce agreement or other court ruling may supersede the birthday rule.
Better safe than sorry to ask for this if you have a divorce or court situation (especially you pedo and ortho offices that see way more of this...)
How dual coverage works
For example, if both of your patient's plans provide two cleanings a year, each with 80 percent coverage, then:
Your patient would not be entitled to four cleanings a year.
Your patient may want to argue this but we promise we are right here...
The primary plan pays its benefit as if there is no other insurance
Yep, you read that right...
The secondary plan will act as a supplement to the primary plan with its payments limited to the lesser of its normal benefit or the patient’s out-of-pocket costs under the primary plan.
Ok, we know some of you are about to send an email right now because you have seen BOTH insurances pay the max amount of the prophy on a single visit. Your office knowingly accepting this is insurance fraud. You need to do the right thing, call the insurance, and request the process of a recoupment. A simple audit can be done and the insurance company will request it anyways. Do not hold on to it, the headache of them recouping it on their own accord by subtracting from another patient's insurance payment is NOT worth it.
What does Non-duplication of benefits clause mean?
Some dental benefit plans have "non-duplication of benefits" provisions. This means that the secondary plan will not pay any benefits if the primary plan paid the same or more than what the secondary plan allows for that dentist.
For example, if both the primary and secondary carriers pay for the service at an 80 percent level but the primary allows $100 and the secondary carrier normally allows $80 for the same treatment, the secondary carrier would not make any additional payment. However, if the primary carrier only pays 50 percent of the dentist’s allowed fee, then the secondary carrier would reduce its payment by the amount paid by the primary plan and pay the difference. In this case, the secondary carrier would pay $14 ($80 x 80 percent - $50 = $14).
Types of coordination of benefits (COB)
Many factors determine how COB is handled, including state laws, processing policies of the carriers involved, contract laws, fully insured versus self-funded plans, and types of COB used.
The ADA has brought us many resources to explain the Coordination of Benefits.
There are many different acronyms, titles, and slang terms for COB methods, here are a few of the most common we have seen.
• Traditional—Traditional coordination of benefits allows the beneficiary to receive up to 100% of expenses paid from a combination of the primary and secondary dental insurance plans.
• Maintenance of benefits (MOB)—This reduces covered charges by the amount the primary plan has paid, and then applies the plan deductible and coinsurance criteria. Consequently, the plan pays less than it would under a traditional COB arrangement, and the beneficiary is typically left with some cost-sharing.
• Carve out—Carve out is a coordination method that first calculates the normal plan benefits that would be paid, then reduces this by the amount paid by the primary plan.
• Nonduplication COB—In the case of nonduplication COB, if the primary carrier paid the same or more than what the secondary carrier would have paid if it had been primary, then the secondary carrier is not responsible for any payment at all. Nonduplication is typically used in self-funded dental plans. A self-funded dental plan is one in which the plan sponsor bears the entire risk of utilization.
• Self-funded plans are exempt from state insurance statutes and are generally governed by the Employee Retirement Income Security Act (ERISA). In 2012, 49% of people with a dental benefit had a self-funded plan. It is important that dental offices understand that not all patients will have a dental plan that is subject to the state’s COB laws. ADA policy opposes non-duplication provisions, and at least one state, California, has enacted legislation prohibiting such provisions.
Network plan write-offs
The difference between the dentist’s full fee and the sum of all dental benefit plan payments and patient payments is the amount of the write-off. Write-offs should not be posted until all plans have paid accordingly. If a write-off is posted after the primary pays and then posted again based on the secondary payment, it is possible the dental office may incorrectly apply a credit to the patients’ balance. Remember to always submit your full fee on the dental claim form.
Medicaid, Medicare, and Coordination of Benefits
By law, all other available third party resources must meet their legal obligation to pay claims before the Medicaid program pays for the care of an individual eligible for Medicaid. Thus, Medicaid is typically secondary to any other benefit plan. In cases that involve a patient presenting with a retiree plan, Medicare and the patient has coverage on a spouse’s plan, generally any dependent coverage pays first, Medicare pays second and any nondependent coverage (e.g. retiree coverage) pays third.
Overall, navigating the path of coordination of benefits can be a frustrating and time-consuming endeavor for dental offices trying to settle accounts for patients with more than one dental benefits plan. In addition, state laws and regulations often mandate coordination of benefits. If after the claim payment has been made and it appears to have been incorrectly adjudicated it is recommended that the claim determination be appealed and if necessary the state insurance commissioner’s office be contacted for assistance. Read this blog twice if you need to. Know what you are looking at and honestly, the success of understanding this all begins with the proper insurance verification.
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