Insurance Predeterminations – Not The Crystal Ball You Think They Are

Insurance companies are often thought of as a necessary evil. When patients need dental care, they will often ask for a predetermination to find out how much their plan will cover. What patients might miss is the fact that often times the insurance company can be a burden, an opponent that we may have to lock horns with, and the predetermination is a great example of how this can play out.

A predetermination is often confused with a pre-authorization. The pre-authorization was done many years ago, and was replaced with a predetermination in the mid 80’s. A pre-authorization was in most cases a guarantee of payment. Patients often believe that a predetermination is a guarantee of how much the insurance will cover (although it isn’t) — that’s why they are willing to wait for it. Insurance companies see this as an opportunity.

Insurance companies begin with the goal of taking in more money in premiums that they are paying out in dental fees. Their goal is to limit dental treatment and pay for as little as possible, which means they are often working against the needs of both the dentist, and their patients.

The Potential Pitfalls of Pre-determinations:

It takes time.

This is often intentional, as it helps the insurance company make money. Patients often won’t commit to an appointment until they receive a predetermination, and in that time, patients slip through the cracks.

A patient may be in need of a crown that could stave off a root canal or tooth loss, but if it isn’t bringing them any pain, they may just forego treatment altogether, losing their sense of urgency after leaving your office. Insurance companies often want this to happen, as that is now a procedure they aren’t paying for.

It takes the dentist out of the decision making process.

In an ideal world, treatment will be between the dentist and the patient. If we decide to go the route of pre-determination, now a third party — with their own priorities — is rocking the boat. The insurance company usually isn’t in the business of looking out for the best interests of your patient.

If you seek a predetermination, the patient will usually base their decision on that information. The biggest problem with your patients basing their decisions on pre-determinations is…

Pre-determinations aren’t binding.

The biggest flaw with pre-determinations is that they don’t mean anything. Patients are forestalling treatment plans recommended by their providers to get a ballpark estimate of what the insurance company might decide to pay for.

Some plans might say they require pre-determinations, they can’t refuse treatment because of the absence of a predetermination. It is important for the patient to understand what they are (and how little they matter), in order to set realistic expectations.

Blog copied with permission from Sunrise Dental Solutions
written by: Linda O’Grady

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