Many employers offer their employees dental care benefits as part of their broader benefits package. Whether you are contracted or non-contracted, you will need to handle third-party claims. When working with employee benefit plans, it’s important to make sure that you are coding properly and following through during each step of the reimbursement process. How can your dental practice effectively handle third-party claims?

Understand the Terms Used for Third-Party Claims

When you are going to be completing third-party claims, it’s critical to understand the terminology that is used. Some of the terms you should know include:

  • Assignment of Benefits: This refers to a patient authorizing the program administrator to make a payment for a covered service to the dentist that is treating them.
  • Bundling of Procedures: When third-party payers bundle claims, they are combining different dental procedures and potentially giving the patient a reduced benefit as a result. What you can bill your patient will depend on whether you are considered an in-network dentist.
  • Changed Codes: Third-party claims can also lead to issues with the code used. Some third-party payers will alter the procedure codes that you submitted based on their processing policies. Even if you submit the best code for the situation, the adjudication of the plan may lead you to receive payments for another code.
  • Coordination of Benefits: The coordination of benefits will happen whenever a patient is eligible for benefits through two or more dental plans. The plans will need to coordinate to ensure that there is not any duplication of benefits or over-insurance.
  • Downcoding: Another unique aspect of working with third-party payers is downcoding. During downcoding, the benefits code that you submit may be “downgraded” to a lower-cost procedure.

Work with the Experts

Handling third-party claims can be challenging and confusing, as you might have ascertained based on the sampling of terms that we included above. Because billing can be much more complex, it is a good idea to work with a partner to streamline and simplify things. It can eat up a tremendous amount of time for your workers to follow up with third-party claims, and it can also start to impact your relationships with your patients. We can help you navigate the world of making third-party claims so that you can have confidence in all that you do. 

Protect Your Business with APEX Reimbursement Specialists

Whether you’re interested in revenue optimization or looking for other services to boost your business, APEX Reimbursement Specialists is here to help. Contact our team today by calling (410) 710-6005. We look forward to working with you to make your practice a more profitable place.