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Out-of-network status: a guide to collections

While being out of network poses its challenges - the right processes, and partnering with experts can help

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In the world of dentistry, navigating insurance claims and benefits can be a complex endeavor, especially for offices that operate outside the realm of network agreements with as many as one, to all insurance companies. While being out of network poses its challenges, with the right systems and processes in place, dental offices can effectively manage insurance claims, handle patient payments, and optimize their operations for success, especially with the help of a dental billing company.  Let’s explore key strategies and considerations for dental offices operating outside of network agreements. 

Out of Network Insurance Reimbursement Scenarios: What is your preference?

When submitting claims to dental insurance companies that a practice is out of network with, a clear process must be defined. There are 3 most common options pertaining to this.  

Option 1:  Inform patients you are happy to file claims on their behalf to their insurance, as well as follow through on the claims to ensure they are paid, optimally, to your practice. With this option, you will want to ensure assignment of benefits within your practice management software is set to the provider. The benefit of this option is attracting and retaining a potentially wider patient base.  

- Follow up tip: Educate patients: Ensure patients understand their insurance coverage and the reimbursement process, including the knowledge that if the insurance company sends them a check, they will need to use those funds to reimburse your office for their dental treatment. 

Option 2: Inform patients you are happy to file claims on their behalf to their insurance, but will NOT follow up on the claims to ensure they are paid. WIth this option, you will file claims and attachments, then close the claim. You will collect your full fees from the patient at the time of service, and they will be reimbursed directly by their insurance company. In this scenario, assignment of benefits is set to the patient within your practice management software. The benefit of this option is that there will be no need to work an insurance aging report for out of network claims. 

- Follow up tip: Encourage patients to follow up with their insurance provider if they encounter delays or issues with reimbursement, and let you know if they need assistance with any additional requested information. 

Option 3: Inform your patients that you will give them the information and guidance needed to submit their own claims to their insurance company for reimbursement and they will be reimbursed directly by their insurance company. In this scenario, you will not create or file claims, and all fees will be collected from the patient at the time of service. This is the least common option as many patients are adverse to filing their own claims. The benefit of this option aligns with option 2, and additionally - you will not need to verify eligibility or really handle any dental insurance issues for out of network claims at all. 

- Follow up tip: Provide documentation - Be prepared to offer patients detailed invoices and receipts, possibly even supporting documentation that they can submit to their insurance company for reimbursement.

Remember the assignment of benefits advice from above? No matter which option is best for your practice, always remember that some insurance companies will pay to the patient when you are not in network, even if you have allocated an assignment of benefits to pay to the provider of services. For more information, we recommend reading the linked article written by the ADA. 

While some dental offices may hesitate to invest in billing companies when operating out of network, these services can still offer significant benefits. Here's how: 

  1. Expertise in insurance billing: Billing companies specialize in navigating the complexities of insurance claims and can optimize reimbursements for out-of-network providers.
  2. Time-saving: Outsourcing billing tasks allows dental office staff to focus on providing quality patient care rather than getting bogged down in administrative tasks - especially if you are still submitting, and/or following up on claims submitted to out of network carriers. 
  3. Compliance assurance: Billing companies stay updated on changes in insurance regulations and ensure that dental offices remain compliant with billing practices. This can be especially helpful if anything in your practice changes - such as adding a new provider, or changing network status. 

Dental revenue cycle management is not just insurance billing and insurance verification - it also includes patient billing, which may be the biggest piece of the revenue puzzle for your practice if you are predominantly out of network.

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