Practice Management

Dental Insurance

A Broad Overview
Laurie A. Evans, M.B.A.
 Topics of Discussion

 HMO / PPO / Medicaid / Medicare
 Dental Benefits
 Insurances taken at UNLV SDM
 Discussion: Ethics - Insurances Influence on Patient
Treatment
 Expectations:
 Questions
 HMO/PPO/Medicaid/
Medicare

 Health Maintenance Organization (HMO): Sometimes
referred to as DHMO in dental insurance.
 Primary Care Dentist
 Referral Based
 Patients cannot use non-contracted, non-referred providers
(non covered)
 Capitation Payments
 Per member, per month (PMPM)
 Not paid by claim
 Patients generally have just a co-pay due at time of visit
 HMO/PPO/Medicaid/
Medicare
 Cont.
 Preferred Provider Organization (PPO): Sometimes referred to as
DPPO in dental insurance.
 Patients can self refer by using list of in-network dentists and dental
specialists.
 If patients use out of network providers they have a higher out of
pocket responsibility
 Providers bill insurance with a claim form and are paid a contracted
amount, in addition to any co-insurance and deductibles the patient
is responsible for.
 Provider responsible to write off the difference between billed fees
and contracted rates. Provider then bills patient for any co-insurance,
deductibles, over annual max, and / or non-covered services.
 HMO/PPO/Medicaid/
Medicare
 Cont.
 Medicaid: A health care program that assists low-income families
or individuals in paying for medical, dental, and custodial care
costs. Coverage varies state by state.
 NV Medicaid Dental Benefits:
 Age 21+: Limited benefits. Emergency extractions, palliative care, and
may be eligible to receive prosthetic care (dentures/partials) under
certain guidelines and limitations.
 Additional coverages with prior auth for adjacent/abutment tooth for
partials
 Age 20 and under: Comprehensive dental care such as periodic and
routine dental services needed for restoration of teeth, prevention of
oral disease and maintenance of dental health (full range of necessary
dental services including orthodontia when medically necessary)
 HMO/PPO/Medicaid/
Medicare
 Cont.
 Medicaid Managed Care Organization (MCO)
 NV Medicaid engages in a contract with a Dental Insurance provider to be the
Managed Care Organization for the majority of the Medicaid population.
 Some Medicaid recipients with certain disabilities, or who live in rural areas, are
exempt from mandatory managed care and will remain in Fee For Service (FFS)
Medicaid (managed by HPES).
 Orthodontic benefits are also carved out (excluded) from the Managed Care
Organization contract and are provided by FFS (HPES), even if the recipient is
enrolled in the MCO.
 As of 1/1/2018 the MCO is Liberty Dental Plan: UNLV SDM is contracted
with the Medicaid line of business for Liberty Dental Plan but not the
commercial Liberty Dental lines of business.
 Liberty has added a few “Added Value Benefits” for the 21+ category to include
1 per year: D0120 (Periodic Oral Eval) and D1110 (Adult Prophy – cleaning) and
additional radiographic images.
 HMO/PPO/Medicaid/
Medicare
 Cont.
 Medicare: Federal health insurance program for people who
are 65 or older, certain younger people with disabilities, and
people with End-Stage Renal Disease
 Dental Coverage: Not really
 Doesn't cover most dental care, dental procedures, or supplies
 Medicare Part A (Hospital Insurance) will pay for
certain dental services that you get when you're in a hospital.
 Medicare recipients often purchase supplement dental plans
from commercial dental insurance companies
 Low premiums
 Not paid by Medicare – agreement is between patient and
commercial insurance plan
 Dental Benefits

 Dental benefits vary from insurance to insurance,
and vary by plan under each insurance.
 Templates set up in patient chart will help identify
what costs are covered by the insurance, and what
the patient is responsible for.
 Dental students will receive training and navigation
regarding what to collect from the patient.
 School policy is that patients pay prior to treatment
for their responsible out of pocket costs
 Insurances Taken at
UNLV SDM
 UNLV SDM will bill all insurance as a courtesy for our
patients.
 Patients are expected to pay their out of pocket costs prior
to treatment
 UNLV SDM is contracted with the major dental insurance
PPOs, and Medicaid Plans
 In network provider = lowest out of pocket for patient with
that insurance
 Patient with insurance UNLV SDM is not contracted with =
out of network provider = higher out of pocket
responsibility for patient
 Discussion: Ethics – Insurance
Influence on Patient Treatment

 Covered benefits
 Prior authorization
 Usually required for procedures $200 and over
 Non covered benefits
 Annual maximum benefit
 Usually about $1500 - $2000
 Never a guarantee of payment (disclaimer)
 Dental records: Electronic Health Record (EHR)
 Accurate and thorough charting can assist with pre-approvals and
claims appeal process
 Radiographs
 Justification
 Expectations

 Progressing into clinic
 Training in axiUm
 Financial Orientations – Pay close attention!
 Patient financial responsibility can = Student financial responsibility
 Clinical Business Office
 Here to help! 
 Email in axiUm: Business Office
 Stop in
 You must clear all charts in your patient pool through financial
before you can route out, progress to next semester, and graduate.
REMEMBER collect your patient’s financial responsibility prior to
each treatment so it does not become your financial responsibility.
Questions
