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Straighten out coordination of benefits with ADA resources

January 16, 2018

By David Burger

Editor's note: This is the fifth in a series featuring answers and solutions for dentists when it comes to the world of dental benefits and plans. The series is intended to help untangle many of the issues that can potentially befuddle dentists and their teams so that they can focus on patient care.

When it comes to determining benefits, C-O-B is often not as easy as 1-2-3.

Decoding Dental Benefits logoCoordination of benefits is when a patient has more than one dental plan and may be able to use both of them to cover dental procedures. When this occurs, the two plans work together to coordinate benefits to eliminate overbilling or duplication of benefits.

But navigating the path of coordination of benefits can be a frustrating, confusing and time-consuming endeavor for dental offices trying to settle accounts for patients with more than one dental benefits plan.

The ADA has online resources to help answer questions from member dentists and their dental offices regarding coordination of benefits.

A members-only resource, the ADA Center for Professional Success website Success.ADA.org , houses information on coordination of benefits at ADA.org/coordinationbenefitsintro. From there, the ADA Guidance on Coordination of Benefits is available at ADA.org/COB, which includes information on general coordination of benefits rules and types of coordination of benefits, among other subjects.

State laws and regulations often mandate coordination of benefits, said Dr. Brett Kessler, chair of the ADA Council on Dental Benefit Programs' Dental Benefit Information Subcommittee. "If after the claim payment has been made and it appears to have been incorrectly adjudicated, it is recommended that the claim determination be appealed. This information, along with state-specific information on coordination of benefits, can be found by visiting Success.ADA.org."

Important things to remember, said Dr. Kessler, when dealing with coordination of benefits include:

  • Only group (employer) plans are required to coordinate. So if one of the policies covering a dentist's patient is an individual policy, then it does not coordinate.
  • When both plans have coordination of benefits provisions, the plan in which the patient is enrolled as an employee or as the main policyholder is primary. The plan in which the patient is enrolled as a dependent would be secondary.
  • The typical rules for dependents of parents with overlapping coverage rely on the "birthday rule," in that the parent with the earliest birthday in a calendar year is primary.
  • In the case of nonduplication coordination of benefits, if the primary carrier paid the same or more than what the secondary carrier would have paid if it had been primary, then the secondary carrier is not responsible for any payment at all. ADA policy opposes nonduplication provisions and at least one state, California, has enacted legislation prohibiting such provisions. Nonduplication of benefits is typically used in self-funded plans which are generally exempt from state insurance laws.
  • Medicaid is typically secondary to any other benefit plan.
  • When a patient has coverage under both a medical and dental plan, the medical plan is typically primary (except in Nevada for oral surgeons only).
  • The National Association of Insurance Commissioners has drafted model regulation on coordination of benefits and recommends that states pass similar legislation so that benefits can be coordinated uniformly across states. The ADA supports this and also recommends that state dental associations attempt to pass similar legislation.

Communication between dentists and third-party payers is important, Dr. Kessler said.

"It is strongly recommended that the dental office — assuming the office files claims on behalf of the patient — verify primary and secondary coverage by calling the customer service number on the patient's identification card," said Dr. Kessler. "ADA staff receives many calls where both plans indicate they are secondary. If a dental office cannot determine which plan is primary, it is always a good idea to have the patient contact his or her employer's human resources department for assistance."

ADA staff members also receive many calls on how write-offs should be handled and how much the office can bill the patient in coordination of benefits scenarios.  The ADA has a video titled "Coordinating Benefits: How Much of my Fee Should I Write-off?" which can be found by searching for the name on ADA.org.

Staff from the Center for Dental Benefits, Coding and Quality can help dentists with dental benefits-related problems, questions and concerns. Call 1-800-621-8099 or email dentalbenefits@ada.org for questions regarding coordination of benefits and third-party payer issues.

If dentists have a concern or question they would like addressed in a future issue of ADA News, they can contact dentalbenefits@ada.org.

Dentists and their teams can find additional information on dental benefits at ADA.org/dentalbenefits.