Message Boards
Today's Active Topics Today's Active Cases Browse Forum Categories My Recent Activity My Messages Private Groups My Marked Threads My Subscriptions
Today's Active Images Today's Active Polls Most Active Topics Global Townie Map Advanced Message Board Search Message Board Terms of Use

How to Successfully Administer Insurance in Your Practice by Dr. Charles Blair

Start Discussion

by Charles Blair

Each day dental practices must file dental claims for the procedures performed there. Selecting the proper dental code is important when filing any dental claim, and proper insurance administration is just as vital. Proper administration may differ depending on the type of plan and whether the practice is in- or out-of-network with the payer.

However, there are some areas of dental administration that apply to all claims. Listed below are three categories where dental teams are often in need of additional information and support.

PPO contracts and provider processing policy manuals
The decision to join a PPO is frequently based solely on the contracted fee schedule, without any consideration of the obligations that come with participation. These obligations are detailed in the PPO contract and the associated Provider Processing Policy Manual (the manual).

The PPO contract mandates that the dentist adhere to all of the payer's processing policies. The manual is a separate document that details all of the provider's obligations. This manual often requires that all services be submitted to the payer, even non-covered services (such as teeth whitening, veneers, or multiple crowns). Also within the manual is the PPO's optional services policy which may allow balance billing for non-covered services.

As an in-network, contracted provider, it is imperative that the dentist and business team members fully understand the language of both the PPO contract and the manual. However, many practices do not realize that these documents exist until the practice is presented with a challenge, which may result in hefty, unexpected write offs.

Therefore, a practice should always maintain a current copy of the manual. Many payers provide a copy on their website. To obtain the manual, contact the dental benefit plan's provider relations department.

Summary plan description vs. plan document
Another challenge that practices face is understanding the coverage of dental benefit plans available to their patients. Unfortunately, practices typically have very limited information about patients' plans. It is recommended that the practice verify benefits for each patient. When benefits are verified, the practice may only obtain a booklet (the summary plan description) from the payer. In many cases, the patient receives only the summary plan description.

Each dental benefit plan has its own unique plan document. The plan document is a long, detailed document that contains the dental plan's established criteria. In some cases, it may be up to 200 pages long.

The payer uses the plan document as a guide when administering the plan. The subscriber—or patient—is the only person who may obtain the plan document—the practice does not have access to it. If the dental plan is an employer-provided plan, the employee may request a copy of the plan document from the employer's human resources department.

On the other hand, if the dental plan is an individual plan, the patient can obtain the plan document directly from the payer.

A practice should obtain a few plan documents. Each practice typically has multiple patients who work for large, local employers. The practice could ask one of those patients to obtain that employer's plan document. Having a complete plan document will help the dental team understand the patients' comprehensive benefits. It should also lead to a decrease in claim rejections and denials while improving claim processing time. Most importantly, the plan document will help the dental team improve their treatment plan presentation, benefit explanation, and financial-arrangement offerings. This improved communication can lead to a higher rate of case acceptance and fewer collection issues, and may help maintain patient loyalty over time.

In any case, always report what you do. The dental practice is required to report the CDT code that best describes the procedure performed. The claim is then processed based upon the criteria established by the plan document and any applicable processing policies. Note: The plan document always trumps the provider's processing policy manual.

Unclaimed property
Dental practices typically have old patient credit balances and are often unsure of how to handle them. Credits should not be written off by the practice or transferred to other patient accounts.

There is no legitimate justification to write off a patient credit, even if a patient misses or cancels an appointment. Missed appointments lead to a loss of production for the practice, and thus lost revenue.

Each state has its own unclaimed property regulations. Once a credit has reached the dormancy holding period, as established by state law, the credit becomes unclaimed property. This dormancy period varies by state, but is typically around two to three years. Unclaimed property legislation requires the practice to make a reasonable attempt to return the balance to the patient and most states require that written notification be provided to the patient within a given time period.

If the patient does not respond, the money must be transferred to the state's unclaimed property division along with a report. Each state has a filing deadline and specific requirements, such as, but not limited to, how many days prior to the filing deadline a due diligence letter must be sent to the patient. Contact your state's unclaimed property office for guidance and clarification of your state law.

It is a good idea for a practice to generate a list of patients with credit balances and review all accounts on an ongoing basis, such as quarterly. Keep in mind that if a credit is the result of an insurance overpayment, the refund must be paid to the insurance payer, not the patient. Therefore, it is important to perform an account audit to ensure that the refund is paid to the correct party.

Current subscribers of Insurance Solutions Newsletter and PracticeBooster.com receive coding and insurance administration support. More than half of those support requests are related to insurance administration, not coding. In response to the influx of insurance administration questions, the 250 page Administration with Confidence guide was published to assist dental practices across the country with their administration challenges.

Educating dental team members and providing the necessary resources will ensure successful insurance administration in your practice.



Dr. Charles Blair is an authority on practice profitability, fee analysis, insurance coding strategies and strategic planning in dentistry. He has consulted with thousands of practices where he has helped identify and implement new strategies for greater productivity and profitability. Dr. Blair's extensive background and expertise makes him uniquely qualified to share his wealth of knowledge with the dental profession. He's authored several publications including Coding with Confidence; Administration with Confidence; Diagnostic Coding for Dental Claim Submission; and the Insurance Solutions Newsletter. He also founded Practicebooster.com which optimizes insurance administration and aids in maximizing reimbursement. He holds degrees in accounting, business administration, mathematics and dental surgery. .


Dentaltown Magazine
September 2025
Dentaltown Magazine September 2025 Read Current Issue Read Archived Issues
Sponsors
Townie Perks
Townie® Poll
Who or what do you turn to for most financial advice regarding your practice?
  
Site Menu
Message Boards Magazine Continuing Education Podcasts Blogs Classifieds Dental News Events Townie® Poll Ebooks Townie Choice Awards
Company Info
Contact Us Advertise With Us Howard Farran DDS, MBA Policies and Agreements
Site Help
Sally Gross, Member Services Specialist
Phone: +1-480-445-9710
Email: sally@farranmedia.com
©2025 Dentaltown, a division of Farran Media • All Rights Reserved
9633 S. 48th Street Suite 200 • Phoenix, AZ 85044 • Phone:+1-480-598-0001 • Fax:+1-480-598-3450