A downgrade, also known as an “alternate benefit” in dental insurance, occurs when dental insurance plans opt to cover the least expensive procedure among what THEY deem to be multiple acceptable options. In such cases, patients may still receive the treatment option they choose, but if they choose a more expensive option (typically not covered), they'll incur a higher out-of-pocket expense. Dentists recommend to their patients treatment that best suits their oral health, and health overall - so why would any patient choose what an insurance company wants to pay (in order to save themselves money) over what their dental care provider recommends? The answer is already stated above - out of pocket expense, which can inadvertently lead patients to believe that insurance knows best. Let’s dive into every piece of this common treatment case acceptance, and even revenue bottleneck that so many in the dental field have encountered and map out how to best help patients understand and accept the care they need.
As a starting point, let's review the concept of a downgrade, with a posterior filling downgrade as an example:
Imagine a patient with an insurance plan, such as a 100/80/50 plan where fillings are covered at 80%. However, the insurance company downgrades coverage for composites on posterior teeth to an amalgam restoration.
For instance:
- A posterior composite filling costs $100.
- An amalgam filling costs $80.
Since the insurance's preferred option is the less costly amalgam, the coverage is reduced to covering 80% of the $80, rather than 80% the $100, with the patient owing the difference between the allowed amount of the two procedures, regardless of the composite being the service rendered, and the optimal treatment option.
Some additional common downgrades:
- Inlay/Onlay/Crown to composite or amalgam
- Bridge/Implant to removable prosthetic(s)
- Periodontal Codes to lesser periodontal codes (see our periodontal denial specific blog here!)
- Ceramic or porcelain crowns to metal crowns
Side note: For code and verbiage reference, lean on the ADA’s website, specifically their glossary of dental clinical terminology.
4 Common questions we receive from offices regarding downgrades, and the answers:
- Can patients be charged the difference for a downgrade?
YES!! practitioners are permitted to charge patients the discrepancy resulting from a downgrade.
- Are insurance companies authorized to downgrade procedures even for out-of-network providers?
Absolutely!! Regardless of whether a dental office is in-network or out-of-network, insurance plans dictate the terms, including the possibility of downgrades.
- How do I explain downgrades to patients?
Inform the patient that their insurance provider offers an alternate benefit for the diagnosed treatment, taking the time to explain what an “alternate benefit” is in terms they understand. It's advisable to keep explanations simple and straightforward to avoid unnecessary complexity. Ensure you include WHY you are not recommending the “alternate benefit” as treatment pertaining to their health.
- How do I properly calculate the out of pocket expense for a patient for a procedure with an alternate benefit?
NOTE: Insurance verification is essential to knowing in advance when a downgrade may occur, and should be part of every insurance verification breakdown for the listed common procedures.
Different practice management softwares have different ways to alter payment tables and treatment plans for a somewhat accurate projection of estimated insurance coverage - so we recommend talking to your PMS vendor about the best way to modify that, knowing that simply overriding the percent coverage for a whole plan is not best practice. Understanding the patient's concerns and motivations, as well as your verbiage, can facilitate smoother conversations and treatment decisions in advance, and even when explaining why a patient has an unexpected bill.
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