Suppose a regular patient visits your dental practice for a crown. You treat the patient, and they leave feeling fine, as they expect the payer to cover most of the costs. Three weeks later, you send the patient an invoice with the full amount, because the patient’s employer has switched the payer, but nobody checked. The patient is furious and refuses to pay, and your practice ends up losing $1,400.
Don’t want to be in that situation, right?
But it happens in many dental practices that don’t implement a proper insurance eligibility verification process.
If you want to protect your revenue and reduce the hassle for patients and your practice, this blog assists you. It explains how verifying patient coverage in advance with expert dental RCM services makes claims clean and maximizes collections.
An Overview of Insurance Eligibility Verification
Insurance eligibility verification is the first step in the front-end revenue cycle process for dental practices.
If this step is taken right, then your dental billing process runs smoothly, but if you don’t verify patients’ coverage, the process can go wrong, which leads to claim denials, underpayments, and ultimately revenue loss.
And it happens with most practices that think that it’s just about confirming if a patient’s coverage is active.
That’s a starting point, but it’s nowhere near the full picture.
Being active means the patient is a recognized member of an insurance plan.
But being covered means the specific procedure you’re planning to perform is actually a benefit under their plan. A patient can have a perfectly active policy that excludes the exact CDT code you’re about to submit. If your team stops at “yes, they have Delta Dental,” you’ve only done half the job.
You need to check everything, including what benefits the plan offers to the patient, along with the limitations. When you verify details, it’s easy for you to submit clean claims and bill patients with correct invoices.
What Should Insurance Eligibility Verification Confirm Before Treatment?
Here’s what a complete dental insurance eligibility verification should actually confirm before any treatment begins:
| Component | Description |
|---|---|
| Active policy status and effective dates | Checking if the plan is live on the date of service, as well as its renewal or expiration date. |
| Annual maximum and amount already used | The total benefit offered in the annual coverage, and checking how much of the patient’s annual benefit is still available. |
| Deductible status | If the plan is individual or family, and how much deductible has been paid in the year. |
| Copay | A fixed dollar amount that the patient has to pay at the time of service. |
| Co-insurance | A percentage of the total fee that the patient needs to pay after insurance has covered its share. |
| Frequency limitations | Limitation on how many benefits a patient can avail in a treatment (e.g., 2 cleanings in a year, 1 crown on a tooth every five years, etc.). |
| Waiting periods | The time period during which insurance doesn’t cover a patient’s treatment. If a patient receives treatment during this, they must pay for it. |
| Missing tooth clauses | Checking if the payer covers the replacement of a tooth before the patient’s policy begins. |
| Prior authorization requirements | Checking if high-cost procedures like crowns, implants, or surgical extractions require payer approval before claim submission. |
| Coordination of benefits | Checking if a payer has dual coverage and seeing which plan is primary and secondary. |
It’s important to check all of these items before treating a patient. If you miss any one of these, it leads to claim denial, payment delay, or an unhappy patient standing at your front desk asking why nobody informed them before the treatment.
What is the Benefit of Insurance Eligibility Verification in a Dental Practice?
Let’s discuss how dental practices can benefit from the insurance eligibility verification process.
Higher Clean Claim Rate
When you verify a patient’s coverage before performing a treatment, or at the time of service, you easily find what payers cover and what the patient has to pay.
Plus, you can also verify the patient’s demographics like name, date of birth, and subscriber ID, and match them with the patient’s database in the payer portal.
You can also find a patient’s plan details like the coordination of benefits for primary and secondary claims if a patient has dual coverage. Eligibility verification also informs if a treatment in the patient’s plan requires pre-authorization.
When you verify all the details upfront or in real-time, you submit clean claims that are free of errors. As a result, payers approve and reimburse your claims faster.
Better Patient Experience
Insurance eligibility verification helps you know the share of payer and patient in treatment costs. When your front end staff explains that to the patient in advance, telling them what they have to pay, it reduces the hassle for the patients. They’re financially prepared for what’s coming ahead, and can decide if they want to proceed with the treatment.
It makes patients trust you more than before and billing claims to patients with collections becomes easier for your practice.
Reduced Accounts Receivable
As we’ve discussed, eligibility verification makes your claims clean, which means there are fewer denials and faster payments. With that, just a few dollars sit in accounts receivable.
And it’s important to keep A/R aging low for a healthy dental revenue cycle. The best approach is to keep most of the A/R in the 0-30 day bucket, because it’s easier to recover than aging claims.
When you use a proactive approach like eligibility verification, you can control accounts receivable to a huge extent.
What is the Process of Dental Insurance Eligibility Verification?
Let’s discuss the dental insurance eligibility verification process step-by-step.
Collect Patient Information at Appointment Scheduling
When a patient visits a practice to schedule an appointment, the front office collects the details including a patient’s name, date of birth, and insurance ID. If the patient is dependent on a plan, collect the details of the policyholder, like the policyholder’s name and ID, and also mention the patient’s relationship to the policyholder.
Match Patient’s Details with the Payer’s Records
The billing team verifies details provided by the patient by matching them with the payer’s records. Billers may check them by logging in to the payer portal and entering the patient or main policyholder’s insurance ID. It helps the staff check details like patient name, date of birth, and details related to the patient’s coverage plan, and verify if the patient’s details match the payer’s records.
Get Real-Time Confirmation from the Payer
While the payer portal shows all the details about the patient’s demographics and insurance coverage, the payer may not have updated them, and the staff might be viewing previous details.
So, the better approach is to contact the payer representative and get confirmation in real-time to avoid any hassle. And the billers must document the conversation, to get evidence that the claim has been submitted after verifying details provided at the payer end.
Verify Eligibility and Benefits
Dental practices often confuse insurance eligibility verification and benefits and coverage validation. While both are front-end steps in a revenue cycle and are closely related, it’s important to differentiate between the two terms.
Eligibility verification is used to check if a patient is eligible to receive a treatment. And validating benefits means that billers check which treatments are covered in the patient’s plan, and how much costs are covered by the payer.
Example: A patient can have active Blue Cross Blue Shield coverage that explicitly does not cover implants as a plan benefit. If billers only confirm “yes, BCBS is active,” book the implant procedure, and submit the claim, the claim is going to get denied. The eligibility check said yes. The benefits check would have said no.
So, it’s always important to verify and document both eligibility and coverage before treating patients and submitting claims.
Obtain Prior Authorization for Certain Procedures
Some expensive or complex dental procedures, like bridges, crowns, dentures, implants, and scaling and root planing (SRP) require prior authorization from the approval. When staff verifies eligibility and benefits, they verify which procedures require approval from the payer before claim submission.
If a provider performs such a treatment and if it requires prior-authorization, billers must obtain approval from the payer by sending a prior authorization request. All the documents must be attached to prove that the treatment is necessary for the patient’s health, so the payer can review it and approve it if they deem it important.
If the request is approved, the payer assigns a pre-authorization number, which billers can use in a dental claim form during claim submission, to confirm that payer has approved claim submission for it.
Note: Pre-authorization is not a guarantee of payment, but it fulfills payer requirements for prior approval for dental claims.
Document Verified Details in Patient’s Record
When billers verify all the information from the payer end, whether these are coverage details, benefit amounts, exclusions, and pre-authorization numbers, they should enter them in the patient’s record in a practice management system. These should also be recorded with a timestamp. The documentation secures a practice in case of a patient billing dispute or any legal investigation.
Plus, it also helps improve patient care and further billing processes. Whenever a patient returns for a treatment, the billing team can easily check what was verified before, and proceed with further steps accordingly.
Communicate Patient Responsibilities
After completing all the verification steps, front-end staff explains to the patient what payer covers and what the patient needs to pay for dental procedures. If it’s done before the treatment, it’s much easier for the patient to pay the bills and proceed with it. Plus, patients can set expectations accordingly, and make financial decisions.
What are the Common Issues in Dental Insurance Eligibility Verification?
Let’s discuss the common issues dental practices experience during insurance eligibility verification, with practical solutions:
Manual Verification Errors
When billers verify details manually via handwritten notes, phone calls, or spreadsheets, the obtained information is always prone to errors. A misread policy number or a missed co-pay amount results in billing errors, affecting the entire revenue cycle.
Fix: Automate eligibility verification using a billing software that’s integrated with your payer portal. With automation, details are verified and cross-checked in real-time, eliminating the likelihood of errors that come with manual verification.
Outdated Patient Data
Payer portals may not always have updated data, due to which when you verify details, you may receive outdated data. And when you submit claims using it, these claims are prone to denials.
Fix: Make sure to cross-check the patient data with the payer representative when verifying eligibility and coverage for every claim. Don’t just rely on the payer portal. Contact the representative and confirm each detail, and document everything in the conversation.
It’s solid evidence for your practice to contest a payer decision if a claim is denied. You can appeal it with evidence that you have submitted a claim using details provided by the payer end during verification.
High Staff Turnover in Front Desk Roles
When front desk staff are occupied with multiple tasks including scheduling patient appointments, dealing with the patients at reception, handling patient communications, and verifying eligibility, they can get exhausted and may not perform properly.
As a result, staff gets dissatisfied and practices experience high staff turnover in front desk roles. So, when you train new members and they end up leaving, it’s a huge strain on your resources.
Fix: Automate front-end tasks like appointment scheduling and eligibility verification via your software. But, if still it’s too much for your staff or they need expertise to operate these tools, outsource your dental RCM to a professional company like TransDental. RCM companies employ experts, who are efficient at managing payer policies and operating billing systems. They can do the tasks much faster, streamlining your billing operations.
It reduces your staff’s workload and can control staff turnover to a huge extent. Plus, you don’t have to worry about staff turnover. Even when you don’t have available staff, RCM partners manage these tasks uninterrupted.
Handling Dual Coverage and COB
If a patient has dual coverage, coordination of benefits must be applied very carefully. However, practices struggle with it, and mistakenly submit the wrong claim first. As a result, it doesn’t just consume time and effort, but also delays payments and makes cash flow inconsistent.
Fix: A patient’s coverage plan mentions the COB order. When you verify it, you can know the primary and secondary plans, and submit claims in the correct order.
Prepare the primary claim first and tickmark the COB field in the dental claim form. After that, submit the claim and receive its explanation of benefits from the primary payer. Attach it with the secondary claim and send the claim to the secondary payer.
If it’s still an issue, hire billing experts to manage the coordination of benefits correctly.
Verifying Insurance Eligibility Just Once
It’s perhaps among the biggest errors in eligibility verification. When a patient schedules an appointment with a dentist, the dental practice verifies the patient’s coverage and then relies on it for the entire billing process.
But, the thing is that the patient’s coverage details can change anytime. A patient may switch jobs, employer may switch to a different insurance carrier, or a policyholder’s coverage plan may expire or exceed limitations. Plus, payers may modify frequency limitation rules and other coverage details anytime.
A patient’s detail may not be the same at the time of service as it was while scheduling an appointment.
So, billers, which rely on one-time insurance eligibility verification, experience claim denials fast.
Fix: Verify patient details on every visit to make sure that the details or policies in the plan haven’t changed. If there are changes, check them before treating a patient, and plan the treatment accordingly.
Are You Ready for Clean Billing?
Eligibility verification is a key step in a dental revenue cycle. If it’s managed right, claims are submitted correctly, and reimbursements are fair, keeping your finances smooth and cash flow consistent.
Make sure to verify all the patient details at every step, and use automation to perform routine verification tasks fast. And if you have a high volume of patient claims, outsourcing is the best option, which relieves your staff of routine billing processes, helping them manage other tasks, while your partners help verify coverage, submit clean claims, and maximize collections for your practice.
Frequently Asked Questions (FAQs)
How far in advance should we run insurance eligibility verification before a patient appointment?
While many practices check coverage upfront, TransDental’s real-time eligibility verification is the best approach, where you can cross-check details on the spot. You should check the patient’s eligibility at every visit, whether at the time of appointment scheduling or at the time of service.
What exactly should we be confirming during a dental insurance eligibility check?
A complete verification should cover active policy status, effective dates, annual maximum and remaining benefit, deductibles, co-insurances, frequency limitations, waiting periods, any missing tooth clauses, prior authorization requirements, and coordination of benefits for dual coverage.
What happens if we treat a patient and the insurance turns out to be inactive?
If you submit a claim and the payer discovers the patient was ineligible on the date of service, they can recoup the payment, even months after you’ve already received it, by adjusting it in future payments. In that case, you need to bill the patient directly. You may also document a timestamped record of eligibility verification if you have utilized it.
Can we rely entirely on payer portals, or do we need to make phone calls too?
For routine appointments, like a recall exam, a cleaning, and standard X-rays, portal verification can be reliable. But for major restorative or surgical procedures, prior authorization requirements, or any case where the portal data is inconsistent with the patient’s insurance card, consider calling the representative.
Should we keep insurance eligibility verification in-house or outsource it?
Keeping verification in-house or outsourcing depends on your billing requirements. With in-house, you need dedicated staff and billing expertise for the task, while dealing with staff burnout and turnover. By outsourcing to TransDental, you can work with billing experts who verify patient coverage in real-time and help you submit payer-approved claims and free up your staff.
