Coverage Conversations:

Preauthorization

Some surprises are great!  Unfortunately, more often than not, many surprises result in disappointment, hardship, or embarrassment.  Too often, dental insurance surprises are usually of the unfortunate kind.  Something we expected to be covered isn’t or the amount of coverage is less than expected.  This is especially true when we’ve submitted planned treatment for an estimate of coverage and then the actual coverage is less than what was reported.

Dental insurance companies like it when dentists submit for planned treatment.  It allows them to anticipate future liabilities and generally slows the process which benefits them by allowing them to keep collected premiums in investment accounts longer.  They also know that patients may reconsider going ahead with treatment as time passes.  Patients may benefit from being able to plan for their share of the costs, but only if the estimated coverages provide them with an accurate number.  Delaying treatment may also lead to more complex or uncomfortable problems.

Patients often assume that the dental insurance company has “preauthorized” their treatment but receiving an estimate back from the company does not guarantee that the claim following treatment will be approved or that it will pay at the estimated levels.  This “surprise” outcome can be frustrating and result in unanticipated costs for treatment.  Dentists and patients that counted on this information to make plans cannot undo the treatment that was given when the parameters are changed after the actual claim is submitted.

Recent years have seen legislation that reasonably restricts “surprise billing.”  These laws protect patients from unexpected expenses but usually leave providers bearing the responsibility for unpaid treatment when the amount of coverage is less than anticipated.  No one wants to see patients experiencing debt arising from essential health care, but it is unfair to make providers bear the debt when it arises from lack of anticipated coverage, especially when an effort to determine it was made ahead of time.

Requiring dental insurance companies to honor the amounts of coverage they reported themselves in advance of treatment is reasonable.  They should do their own due diligence in determining eligibility and levels of coverage as part of the procedure.  While unforeseen circumstances may require changes to the original treatment plan and can be disclosed to the patient at the time of treatment, patients should be able to count on the fundamentals of the estimated coverage and not have to be concerned that coverage will be denied for a reason that could have been determined and anticipated through the process. 

Many states have adopted legislation that requires dental insurance companies to honor the coverage that was reported on preauthorization requests.  New Mexicans also deserve this protection.  Most already assume that they can count on the information they are receiving.  It’s time to make this assumption a requirement for companies.