Preauthorizations are important when it comes to procedures that are considered “major”, or cost $300.00 and up. There are a few other procedures that don’t fall into the “major” category, such as scaling and root planning, that should also be preauthorized.
Pre-authorization is a simple task that the billing manager takes care of. When a procedure, such as a crown or bridge, needs to be preauthorized she sends a letter and claim to the insurance company asking for them to let the office and the patient know how much of it they will cover and how much the patient is expected to cover. Sometimes an x-ray or several x-rays are needed for the preauthorization to be accepted, and sometimes periodontal charting is needed as well. All of these are sent with the preauthorization to help our case as to why the patient needs the procedure.
Insurance companies have 30 days from the time they receive the information to make a decision about the procedure that is being preauthorized. If you decide to schedule the procedure before you leave the office, this is the main reason we schedule the procedure out so far in advance: to make sure we have the preauthorization back in hand before starting the procedure.
Both the office and the patient will receive a copy of the preauthorization determination from the insurance company. This determination will state whether the procedure is going to be covered by the insurance, how much was asked of the insurance company, how much the insurance company SHOULD pay, and how much is the patient’s responsibility. Just because an insurance states they are going to pay a set amount, does not guarantee that this is the amount they actually pay, and then the patient is responsible for the remaining amount. Sometimes insurances state they will pay a certain amount, but didn’t have all current procedures that have already been done for the patient during that benefit period accounted for. This can adjust the amount the insurance pays if the patient has met their maximum or already met their deducible elsewhere. These are adjustments that we have to take into account when the actual procedure is being billed to the insurance company once it has been completed.
Preauthorizations are an important part of dental treatment for both the patient and the dental office. It allows the patient and the office to know how much the patient is going to have pay, and how much the dental office should not only be receiving but also how much they have to write off as well. If a dental office is a participating provider with an insurance company, they have to accept the fee that the insurance company states is a reasonable price for a procedure. This means that the patient is not allowed to be charged the difference between the dental office’s fee and the insurance’s fee.
Without a preauthorization, an insurance company has the right to deny payment for a procedure, even if it is stated in the patient’s insurance plan benefits that it is covered. The patient is then responsible for the full amount. So don’t go unauthorized and possibly have to pay the full amount! Make sure you’re major procedures are being preauthorized to help save you money.
I you have any questions about preauthorizations or your insurance in general, please contact our billing manager, Brittany Winland, either by phone: (304) 598-5108, or by e-mail: firstname.lastname@example.org .