Transitioning to the clinic portion of dental school comes with a lot of changes. Navigating the intricacies of dental insurance shouldn’t be one that you worry about. Whether your patient has private dental insurance or a public plan through Medicaid, there is some basic terminology that is universal. Being able to speak the language of dental insurance will help you better communicate with your patient and get through the world of clinic. In addition, it’ll help you communicate with insurance companies after dental school and become an active participant in the legislative conversation regarding health insurance. Here is a list of the top five dental insurance terms you should know before entering clinic.
1. What is a co-pay?
A co-pay is a set dollar amount a patient is responsible for paying out of pocket for a covered service. For instance, let’s say a patient’s dental insurance plan allowed amount for an office visit is $100, and your co-pay is 15 percent. The patient would be responsible for 15 percent of $100, or $15. This amount may also be required at the time of a dental procedure.
2. What is a deductible?
An insurance deductible is the minimum amount that must be paid before the insurance policy pays for anything. For example, if the deductible is $200 and the covered individual’s procedure is $179, the insurance does not kick in and the individual pays the entire amount.
3. What are CDT codes?
Current Dental Terminology (CDT) is a combination of letters and numbers that denote a dental procedure. For example, D1110 is the code for an adult prophylaxis procedure. These codes are updated yearly by the American Dental Association. The purpose of these codes is to achieve uniformity, consistency and specificity in accurately documenting dental treatment. One use of the CDT code is to provide for the efficient processing of dental claims and another is to populate an electronic health record.
4. What is a yearly maximum?
The majority of dental insurance companies cap the amount of annual coverage for their subscribers. Coverage maximums typically range from $1,000 to $2,000 per year. Once the yearly maximum is reached, patients must pay for 100 percent of any remaining dental procedures.
5. What is a prior authorization?
A prior authorization is a decision by the dental insurer or plan that a dental service or treatment plan is necessary. This is sometimes called prior approval. It is imperative that prior authorizations be sent out before a procedure is started to ensure both you and your patient know if your treatment plan will be covered by insurance.
Once you fully understand dental insurance terminology, it becomes much easier to communicate treatment in relation to how it impacts your patient’s insurance plan. For example, if you would like to fabricate a denture, it is important that you see if a prior authorization is needed. If it is, it can be sent, and you can wait for a response from the dental insurance company. Being aware of this dental insurance matter and communicating what it all means to your patient can save you a lot of headaches down the road.
Furthermore, many of the policy and legislative matters facing dentistry today pertain to insurance. This past April, over 400 ASDA members visited Capitol Hill to lobby for health care reform that would support oral health. ASDA lobbied for transparency on: (1) premium and benefit plan summary information, (2) out-of-pocket costs, (3) quality, (4) network adequacy and (5) directories of participating health care professionals. Being familiar with the language of dental insurance is integral in this lobbying process, as it allows you to be a member of the national conversation on health care reform and helps you stay actively involved in the legislative process. And, at the end of the day, this will benefit both the patient and provider.
~Michelle Szewczyk, Detroit Mercy ’19, Districts 6-7 Legislative Coordinator