Maximizing Benefits on Patient Exams

Most offices are aware of initial and recall exam frequencies that are found in different insurance contracts and their differences; i.e. two exams per year vs. one exam every six months with a limitation of two in a year.

What most offices do not know is that most insurance companies do not distinguish between the types of exams for which they impose frequency limitations and who performs them.

For example, you perform a comprehensive exam for a patient and then refer them to a specialist, who performs an emergency exam 2 weeks later. Under many plans, you will receive benefits for the first and benefits will be denied for the second because it was performed within the 6 month limitation. Although the patient is responsible for the fee for the second exam, (it is considered a non-covered benefit), it can cause confusion between the practitioners and the patient.

And then there is the scenario: a patient calls your office and, from his/her description, you determine that the patient should see an endodontist. You perform a comprehensive exam 2 weeks later. Many plans will reimburse the endodontist for the focused exam but your comprehensive exam (which would receive more benefits from the insurance company) will be ineligible for benefits because of frequency.

Learn and understand your patients' benefits.

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