Making the 'alternate benefit' profitable

The majority of insurance companies define an alternate benefit as a provision that helps determine how payment will be made when there are several “clinically accepted” dental services that can satisfactorily correct the dental dentition. Kyle Summerford goes through three examples and explains how these downgrades simply leave room for you to charge the patient additional monies out of pocket, which calculates into more income.

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So what is an alternate benefit?

The majority of insurance companies define an alternate benefit as a provision that helps determine how payment will be made when there are several “clinically accepted” dental services that can satisfactorily correct the dental dentition.

In other words, “we pay for the least expensive treatment option” that still provides a functioning dentition. Most insurances clearly state “the member is responsible for a more expensive treatment should you choose to do so.” Though very few patients are aware of this, mainly because they fail to read the fine print documented in their benefits booklet. See the three most common examples below.

Example No. 1 — Upon examination, deep caries is noted on a posterior tooth. Most insurance companies will pay for an amalgam regardless of what option is chosen for that tooth. If the patient opts for a porcelain inlay/onlay or even a posterior composite resin, the patient is then responsible for the fee set by your office, which would be the cost difference between the two — the amalgam and what the insurance company calls it, “the more expensive option.”

Example No. 2 — Upon examination, decay is noted under a posterior crown due to open margins. The majority of insurance companies will pay for the alternate benefit; a replacement so long as a crown has not been placed within the replacement exclusion period (typically five to eight years prior). The insurance will usually pay for a Full Cast Restoration only and not a Porcelain Fused to Metal Crown because it is a posterior tooth and the insurance company chooses not to pay for facings on posterior teeth. Had this been an anterior tooth that needed the same treatment, the insurance company would have opted to pay for a composite resin or possibly a PFM Crown. Therefore, if the patient opts for a Porcelain Fused to Metal Crown, All Porcelain Crown, or a High Noble Crown, the patient is then responsible for the fee set by your office, which would be the cost difference between the two.

Example No. 3 — Upon examination, the patient has a few missing teeth on each side of the upper and/or lower dentitions. The majority of insurance companies will pay for the alternate benefit; a removable prosthesis (i.e., partial denture) so long as a removable prosthesis has not been placed within the replacement exclusion period (typically five to eight years prior). Should the patient choose to have a bridge placed or implants, the patient is then responsible for the fee set by your office, which would be the cost difference between the two.

So as the treating dentist, what does the insurance “alternate benefit” mean to you?

It’s very straightforward; these downgrades simply leave room for you to charge the patient additional monies out of pocket, and this calculates into more income.

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Kyle L. Summerford received his B.S. from St. Johns University in Queens, N.Y., with a major in biology. Over the last 12 years of working in the dental field, he has learned the business aspects of dentistry from some of the most successful dentists located throughout the tristate area. He offers free online education to dentists and their staff members on his practice management website www.rescuemydentalpractice.com. His innovative management and marketing strategies have been proven effective in minimizing overhead costs and increasing production and collections, leading to a healthy, successful dental practice. You may contact Mr. Summerford by email at dentalpracticeoptimization@gmail.com, or via his website at www.rescuemydentalpractice.com.

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