Coordination of Benefits Mini Master Class

Unlock the secrets to navigating the often-confusing world of dental billing with our latest episode, where we promise to make the coordination of benefits (COB) your new superpower. When a patient is juggling multiple insurance plans, determining the primary insurance can feel like solving a complex puzzle. We'll walk you through the essential rules and scenarios, including the role of the patient's employer's insurance, the birthday rule for dependent children, and the significance of the custodial parent's plan. Plus, we dive into the critical understanding of whether an insurance plan includes a COB clause, and what to do if it doesn't, to ensure your claims are never delayed or rejected.

Our mini master class is designed to empower you with the knowledge to avoid potential audits and reimbursement issues. Discover why non-duplication of benefits can be a game-changer in your billing strategy, and learn how to make the secondary insurance work for you when the primary has already paid its share. I'm passionate about equipping you with practical tools for smarter billing practices. Whether you're a seasoned professional or just starting out, you won't want to miss this opportunity to sharpen your skills. Grab your notepad and let's transform your approach to dental billing together. Don't forget to reach out with your questions and share this episode with colleagues who could benefit from these insights!

Want to learn Dental Coding and Billing? Join here:

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Would you like to set-up a billing consultation with Ericka or Jen? We would love the opportunity to discuss your billing questions!

Email Ericka:
ericka@dentalbillingdoneright.com

Email Jen:
jen@dentalbillingdoneright.com

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Want to know what your fee should be for D4346? Send Ericka an email to ericka@dentalbillingdoneright.com

Chapters

• 0:00 Coordination of Benefits in Dental Billing
• 12:23 Mastering Dental Billing for Successful Claims

Transcript

Speaker 1: 0:25

Hi friends, welcome back to another episode of the Dental Billing Podcast, where we dive into insurance ins and outs all things dental billing so that you can work smarter, not harder. Today we are diving into the topic that can be a little tricky for most billers out there coordination of benefits. We're gonna spend some time breaking it down, going into more details so that we understand how to properly position primary, secondary, birthday rules and all the things that we need to understand about coordination of benefits. Have you ever been confused about primary and secondary and stared blankly at an EOB? I think we've all been there. Sometimes we're wondering if you can even build a secondary. Should I build a secondary? Am I supposed to build a secondary? How does a secondary plug into all of this? If you've ever found yourself confused, then I want you to take out a notepad and a pen, because this is definitely an episode that I'm going to call a mini master class and you're going to want to take notes, especially if you are bewildered by coordination of benefits. All right, so we're going to get started with the basics. We're going to start off with what is coordination of benefits In the simplest terms, the way I describe coordination of benefits is the process insurance companies use to determine who is going to pay first when a patient has multiple insurance plans, so let's just say, a patient that has dual insurance. It is there to ensure that there's no double dipping or over billing for any services that we render to the patient. It's about getting the maximum benefit for your patient while avoiding conflicts between insurance plans, and why this is so important is because it keeps claims from being delayed or rejected and it helps us to bill correctly, because we all know that the more accurate we are with our claims, the faster we can get paid, and insurance companies use the rules laid out in the coordination of benefits regulations so that they don't overstep each other.

Speaker 1: 2:47

Now let's talk about one of the most common questions billers ask with regards to coordination of benefits. When a patient has two insurance policies, the question is which insurance is primary. The first step is to look at whose name is on the insurance policy. Generally, the insurance under the patient's own employer or personal plan is going to be primary, but if we're dealing with dependent children, things change, and here's where the birthday rule comes in and we're going to talk about standard coordination of benefits and then not so standard coordination of benefits. But let's first talk about how this scenario works out. The parent whose birthday falls first in the calendar year provides the primary insurance plan. If dad's birthday falls in April and mom's birthday falls in June, dad's plan is primary, right. But here's the caveat. That's only when the parents live in the same household. Okay, if the child is living with mom and dad live separately, then mom's insurance will be primary, regardless of the birthday rule. So that is the caveat to the birthday rule. When we're talking about dependent children Only use the birthday rule if the parents both live under the same roof. So we'll just say if the parents are married, then it is going to be which birthday falls first within the calendar year. If they're divorced, living apart, then it's going to be the custodial parent that is going to be primary. So make sure that you are documenting that and if you know that the parents are not under the same household, then make sure you find out who has custody of the child or who the child resides with, so that you can properly position primary and secondary.

Speaker 1: 4:48

Now I want to jump into plans that do not have a coordination of benefits clause. I'm going to pause and I'm going to mention a side note. I review on a regular basis insurance breakdowns and one question. There's a few questions actually, but since we're talking about coordination of benefits, I'm going to stick to this subject. There is a question that is often not asked on a insurance breakdown. A lot of times I see that offices are relying on the breakdown you get through the insurance portal. Sometimes it'll tell you whether or not the plan has a coordination of benefits clause in it and sometimes it won't. But we need to know. When a patient has dual coverage, we must, must must know if that plan has a coordination of benefits clause. Because if a plan lacks a coordination of benefits clause, it automatically becomes the primary plan. Why? Because it won't consider any other insurance when processing the claim. So you'll submit the claim to that plan first. Then, if there's a remaining balance, you can send it over to the secondary. So earlier I mentioned standard coordination of benefits. When both plans have standard coordination of benefits, they will talk to each other. When a plan does not have coordination of benefits, that plan automatically becomes primary. I want that to sink in the plan without a coordination of benefits clause automatically becomes the primary plan. Write that down. The plan that does not have a coordination of benefits clause automatically becomes primary.

Speaker 1: 6:50

It's really important that we understand all the things that go into how we establish primary and secondary so that we don't jeopardize having to give money back down the line right, because insurance companies will audit what they have paid and one of the things that they are looking for when they're doing a right to recovery audit, which is done behind the scenes. They just want to know that they're paying their claims correctly. They're looking at reasons to get reimbursed right, like collect the money they paid because they paid inaccurately. So they're going to look for primary and secondary positioning and they're going to use these rules to do that. Start understanding how primary and secondary are established. Now, what do we do when the patient has a non-duplication of benefits clause in it? This non-duplication of benefits also falls under that 50-page document, the coordination of benefits regulations. This is one of the rules under coordination of benefits.

Speaker 1: 8:00

Non-duplication means that the secondary insurance won't pay if the primary insurance has already covered the allowed amount for the procedure. Let's break it down even further. I'm going to give you an example of a procedure that is $200 and it's covered by the primary plan at 80% and they pay 160. And the secondary might say, no thanks, the primary already covered it. So whenever you see a non-duplication clause, know that the secondary might not contribute if the primary has met or exceeded what it would have paid. Understanding A non-duplication of benefits is only going to apply to the secondary plans B.

Speaker 1: 8:46

It's not going to pay if, say, for the crown, both plans pay at 80%. If the secondary plan covers the crown at 90%, 80% or greater, they're not going to participate in payment. So the question now becomes can I charge the patient if the secondary doesn't pay? And that answer is going to depend on a few things. If the primary plan has covered the procedure in full or the full allowed amount, then the patient's responsibility is only their co-pay, their deductible according to the primary's plan, but nothing extra. So make sure that you're following your primary insurance's allowed amount, especially if your office is in network with the primary. If you're out of network with both plans, you have a bit more flexibility, but should always keep the patient informed about what to expect.

Speaker 1: 9:44

There is another question that I get asked often and it is should I bill the secondary if the primary covered the procedure at 100%? If the primary has already covered the procedure at the full contracted rate, then there's nothing left for the secondary to pay. Billing the secondary in this case is overbilling. So we don't want to do that. We want to avoid overbilling and that's the purpose of understanding the coordination of benefits clause. This is also going to save you time. It's going to reduce paperwork and it keeps the billing process clean and efficient. And that's what we want to have right. We want to submit clean claims and we want to keep the billing process efficient.

Speaker 1: 10:27

So at this point I think you get the gist of understanding how the coordination of benefits rules apply to a patient who has dual coverage. And the real benefits for an office that masters coordination of benefits are going to be that you're going to reduce claim rejections we're going to and by fewer rejections that means a faster billing process and better cash flow, because, at the end of the day, no one likes waiting around for payment. Okay. And secondly, maximizing patient benefits is also going to build trust with the patient. When patients see that you're helping them get the most from their coverage, they're going to remember that An efficient coordination of benefits process means that less time is going to be spent on appeals and more time for revenue generating tasks.

Speaker 1: 11:22

I wasn't kidding when I said this was going to be a mini master class, but I really have touched base on the key elements of understanding coordination of benefits. It's really important that we understand A how to position primary and secondary. It's really important that we understand how to read the EOBs and apply adjustments or credits. It's really important that we understand the idea of the coordination of benefits clause, meaning if one plan does not have the coordination of benefits clause meaning if one plan does not have the coordination of benefits clause, then that plan automatically becomes primary. And by knowing all of this, this should alleviate the stress and confusion that can be created by not understanding how to properly position primary, secondary and, ultimately, how to post payments when a patient has dual coverage.

Speaker 1: 12:23

I hope that you found today's episode helpful. Please share it with a colleague or give us a review. It would greatly help me reach more people like you who enjoy this podcast. As always, if you have any questions about coordination of benefits, drop me a message, because there's nothing we love more than helping you master the art of dental billing. Okay, friends, until the next episode.