Thursday Troubleshooter: Primary and secondary dental insurance woes
QUESTION: We have a patient with dual insurance. We’re not in network with the primary but are in network with the secondary. We billed out our fees to the primary and they paid their portion. We submitted to the secondary, and they subtracted what the primary paid from what they would pay. This resulted in either no payment or very little payment from them. Do we have to write off the difference between our fee and the contracted fee with the secondary insurance, even if they do not coordinate benefits?
ANSWER FROM SHELLEY RENEE, Shelley Renee Consulting:
It’s always good to ask when you’re unsure! With dual coverage you have what’s referred to as coordination of benefits, or COB. There are many types of COB. Traditional COB means that both companies share the burden of payment up to and never to exceed 100% of the fee charged. In your example, the primary paid its portion and the contracted secondary paid to the limit of its responsibility. This limit would be outlined in your contract.
There is another type of COB called non-duplication. Here is the definition: “In the case of non-duplication COB, if the primary carrier paid the same or more than what the secondary carrier would have paid if they had been primary, then the secondary carrier is not responsible for any payment at all.”
Maintenance of benefits
Maintenance of benefits (MOB) reduces covered charges by the amount the primary plan has paid, and then applies the plan deductible and co-insurance criteria. Consequently, the plan pays less than it would under a traditional COB arrangement, and the beneficiary is typically left with some cost sharing. Check out this link at ada.org.
It sounds like your secondary paid the difference up to the contracted amount, or their limit of responsibility. To answer your question—yes, you must write off the difference in the contracted fee. Never collect more from a patient than their portion of the contracted amount. Ask the contracted insurance company to provide you with their processing policy manual. The manual will clarify what you can do in these situations.
ANSWER FROM CHRISTINE TAXIN, founder of Links2Success:
There is no simple answer to this question. The office must know the type of coverage rules for the plan they’re in network with. If you have dual it can have rules in the plan. You must contact them and follow the wording here to get a definitive answer.
“When you are covered by two dental plans this is called ‘dual coverage.’ This does not ‘double’ your coverage. However, it may reduce your out-of-pocket costs. Dual coverage works the same way whether you are covered by two plans. Primary simply works with the other insurance company to coordinate your benefits.”
Which plan pays first
The plans set forth rules to determine which plan pays first (primary), and which plan pays afterwards (secondary). The general rule is that the plan that covers you as an enrollee is the primary plan and the plan that covers you as a dependent is the secondary plan.
How dual coverage works
For example, if both of your plans provide two cleanings a year, each with 80% coverage, then:
• You would not be entitled to four cleanings a year.
• The primary plan pays its benefit as if there is no other insurance.
• The secondary plan will act as a supplement to the primary plan with its payments limited to the lesser of its normal benefit or the patient’s out-of-pocket costs under the primary plan.
Non-duplication of benefits clause
Some dental benefit plans have "non-duplication of benefits" provisions. This means that the secondary plan will not pay any benefits if the primary plan paid the same or more than what the secondary plan allows for that dentist.
For example, if both the primary and secondary carrier pay for the service at 80% but the primary allows $100 and the secondary carrier normally allows $80 for the same treatment, the secondary carrier would not make any additional payment. However, if the primary carrier only pays 50% of the dentist’s allowed fee, then the secondary carrier would reduce its payment by the amount paid by the primary plan and pay the difference.
In this case, the secondary carrier would pay $14 ($80 x 80% - $50 = $14).
Traditional—Traditional coordination of benefits allows the beneficiary to receive up to 100% of expenses from a combination of the primary and secondary plans.
Non-duplication COB—In the case of non-duplication COB, if the primary carrier paid the same or more than what the secondary carrier would have paid if they had been primary, then the secondary carrier is not responsible for any payment at all.
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