HOW TO NAVIGATE ORTHO WIPS!

Navigating Orthodontic Billing: How to Handle Work-in-Progress Claims When a Patient Acquires New Insurance Mid-Treatment

Managing orthodontic billing can be complex, particularly when a patient changes insurance mid-treatment. The transition needs careful handling to ensure the continuation of benefits and avoid delays or denials. Here’s a step-by-step guide to help you successfully bill a work-in-progress orthodontic claim when a patient switches insurance:

1. Gather New Insurance Information Promptly

Update Patient Records: Ensure that all patient records reflect the new insurance details, including the policy number, group number, and effective date.
Verify Coverage: Contact the new insurance provider to verify orthodontic coverage, including any differences in lifetime maximums, orthodontic limitations, and specifically in this instance whether or not the plan covers treatment in progress.

2. Review the Original Orthodontic Contract

Assess Treatment Timeline: Determine how far along the patient is in their treatment and compare it to the originally approved plan. This helps in understanding what has been billed and what remains.
Recalculate Benefits: The original insurance may have paid a portion of the total treatment cost. You’ll need to calculate what has been paid, what was expected, and what the new insurance will cover.

3. Submit a Termination Claim to the Old Insurance

Acquire proof of termination: Contact the termed insurance policy to get a proof of loss coverage. Depending on the new payer restrictions, the new payer may accept a letter or other proof from the prior carrier provided by the office but on occasion, the new payer may require the patient to call with the term information from their prior coverage.
Include Details: Make sure to include details such as the total fee for treatment, the amount already paid by the previous insurance, and the remaining balance.

4. Create a New Claim for the New Insurance

Get the Details: Call the new insurance company and inquire how they prefer to process a work in progress claim and then submit the information as requested. This process can vary by payer. For example, Blue Cross Blue Shield requests that a new comprehensive claim be submitted with the details referenced above and they also request the D8670 claims as they pay monthly on receipt of the periodic ortho claim.
Start with a Continuation Claim: When billing the new insurance, label the claim as a continuation of treatment. Provide a summary of the treatment already rendered and the amount previously paid by the old insurer.
Submit a New Pre-Authorization If Required: Many insurers require a pre-authorization for ongoing treatment, so submit this with the necessary documentation, including treatment notes, X-rays, and financial records.

5. Adjust Payment Schedules and Contracts

Recalculate Patient Responsibility: The switch in insurance may affect the patient’s out-of-pocket costs. Reassess the financial responsibility and update payment schedules if necessary.
Communicate with the Patient: Clearly explain any changes in their financial obligations due to the new insurance coverage. Provide a revised payment plan if needed.

6. Monitor Claims Carefully

Track the Progress: Keep a close eye on the claim as it processes through the new insurance. Follow up regularly to ensure there are no delays or issues.
Handle Denials or Issues Promptly: If the claim is denied or if there’s an issue with coverage, address it immediately. Be prepared to provide additional documentation or appeal the decision.

7. Document Everything

Keep Detailed Records: Document every interaction with both the old and new insurance companies, including phone calls, emails, and submitted paperwork. This is crucial in case of disputes or discrepancies.
Store Correspondence Safely: Ensure that all correspondence and documentation are stored securely and are easily accessible when needed.

Handling a change in insurance during ongoing orthodontic treatment requires attention to detail and proactive communication. By following these steps, you can navigate the transition smoothly, ensuring that the patient’s treatment continues uninterrupted and that your practice receives appropriate reimbursement.

Still have questions? MODPractice has a team of Orthodontic Billing Experts! Don’t hesitate to reach out!