The Alternate Benefit Clause – A Key Determinant of Dental Insurance Coverage

Understanding their dental insurance plan is critical for patients to make importance choices about their dental treatment. Dentists recommend the best treatment for patients based on their needs and wants. However, dental insurance plans come with many clauses and provisions and patients usually count on their dentist to interpret and explain their policies benefit information. Dental insurance verification services play an important role in this context by checking patients’ coverage, out-of-pocket costs, and benefits before services are provided. This allows dentists to provide patients with a pretreatment estimate so that they can prepare for the cost of dental services. One provision commonly found in dental plans that can affect the beneficiary’s coverage in a serious way is the Alternate Benefits Clause.

The Alternate Benefits Clause

The “alternate benefit clause” is a cost containment feature in an insurance plan which states that if there are two or more professionally acceptable dental treatments that will work for a dental condition, the plan will pay for the least costly treatment alternative. This provision, which is also called a “downgrade”, can mean higher out-of-pocket costs for the patient since the insurance company will pay only for the lesser procedure and not for the actual more expensive procedure performed. If the patient chooses the more expensive option, they must pay the difference between the two.

Down grades can apply to many types of procedures. Here are some examples:

• Fillings: Fillings can be done using an amalgam (or silver) or a resin composite (ceramic and plastic compound). Amalgam or silver fillings last ten to fifteen years and are economical. Resin composite fillings or white fillings mimic the natural appearance of teeth, are costlier than amalgam and last five to seven years. Often, insurance plans pay for the cheaper silver filling. This can be explained as follows (www.drmcdowall.com):Suppose the dentist’s fee for white resin filling is $150 and silver amalgam filling is $110. Suppose the dentist recommends the costlier option based on the patient’s considerations and desires. The insurance plan may downgrade this option to the silver amalgam, which costs less. Suppose the plan pays 80% of the silver amalgam fee of $110, that is, $88. The patient’s copay would be $22 (20%) plus $40, which is the difference in the filling types. Of the $150 billed for the white resin filling, the total patient’s cost is $62 and the insurance pays $88.
• Posterior crown: Materials used to make crowns include all-porcelain (white), porcelain-covering base-metal, and all-metal. The all-metal crown is the cheapest and many insurance plans will pay only for this option. In this case, the patient has to pay the difference if they choose a costlier option than the all-metal crown.
• Cracked tooth: A cracked tooth can be repaired using filling material or a crown. If the patient and dentist decide on the crown, which is the costlier option, the plan will pay the allowance for the filling and patient will have to pay the difference for the crown (United Concordia Dental).

Predetermination of Benefits

Dental plans vary widely. Most dental plans are based on the agreement between the patient’s employer and the insurance company. In addition to the Alternate Benefit Clause, limitations such as annual or lifetime maximums ensure control over how much is paid out on a dental policy.

Insurance generally pays at a lower rate for more expensive procedures such as root canals, crowns, and bridges. In order to make an informed decision, patients need to discuss their options with their dentist before they go ahead with their treatment. Most insurance companies require “predetermination of benefits” or an estimate that lists the recommended treatment, along with the proper dental codes, the costs, the teeth involved and a comprehensive x-ray of the patient’s entire mouth. The insurance company will review the estimate and other supporting clinical information to determine what procedure is eligible for reimbursement. Insurance eligibility verification is necessary and critical step before submitting predetermination of benefits and other pre-service requests.

Aetna clarifies that the company will not automatically change a submitted code to a lower cost code (downcoding) or resort to bundling, subject to the following:

• If the professional review of the submitted charges and supporting clinical information indicates that the original coding may have been inappropriate, a submitted code may be changed.
• Aetna will pay claims in accordance with the terms, exclusions and limitations of a member’s dental benefits plan, including, but not limited to, any contractual alternate treatment/alternate benefit provisions.

With the many challenges associated with dental billing and coding, many practices are opting to outsource these tasks. Experienced AAPC-certified coders in a dental billing company would be knowledgeable about CDT and ICD codes as well as payer rules and guidelines and can help providers submit error-free claims and ensure optimal reimbursement. These companies also have dental insurance verification specialists who will confirm patient coverage and benefits prior to treatment, which is important for patient satisfaction as well as provider reimbursement.