«  View All Posts

4 coordination of benefits rules every dental practice professional should know

November 9th, 2021 | 5 min. read

4 coordination of benefits rules every dental practice professional should know Blog Feature

Print/Save as PDF

Do you accept multiple insurance plans at once from patients? 

Are you confused about how to handle multiple dental insurance plans for the same visit? 

Welcome to the club. As an outsourced dental billing company, we see that many office managers and insurance coordinators find coordination of benefits (COB) really confusing, and it’s hard to find absolute answers to all of your COB questions. 

In this article, you will learn the significance of coordination of benefits so that you can apply this knowledge when dealing with multiple insurance plans from patients at your practice. 

Understanding coordination of benefits can help you collect the right amount of money from insurance claims. Plus, it will keep your patients happy when you can explain to them how using their multiple insurance plans works. 

Does your practice accept multiple insurance plans?

Before we dive even deeper into the rules of coordination of benefits, you should ask yourself: do we refuse to accept multiple insurance plans from patients? If so, why is that? 

It’s common for practices to refuse secondary insurance plans when they do not understand the rules of coordination of benefits. We get it, it makes your billing process a little bit more complicated, and it’s a whole new set of rules you have to learn in order to properly send claims. 

If you do refuse to accept secondary insurance, you might be missing out on additional revenue sources for your practice, and an entire pool of patients. Open up your doors to patients with multiple insurance plans to help your practice collect more money. 

To get ready for those new patients, let’s learn more about coordination of benefits. 

DSC05828

What does coordination of benefits mean for dental insurance billing? 

Let’s keep it simple. 

A patient comes into your dental practice and tells you they are enrolled in two different dental insurance plans. This is common with spouses who have insurance plans from their places of work that cover themselves and each other. 

Can these two insurance plans cover their dental procedure... together? Yes, that’s when coordination of benefits comes into play.

Coordination of benefits can be defined as the role that determines the order in which the insurance benefits are considered for reimbursement. It also means the order in which the dental practice is held accountable for filing insurance claims. 

Patients can have up to three or even four insurance plans. Sounds crazy, right? That’s why each plan has established coordination of benefits rules. With each plan having an established rule, you are required to adhere to those established rules of each plan. 

If a patient has multiple insurance plans, does that mean they have less to pay out-of-pocket?

Your patient has multiple dental insurance plans. This means more coverage, which means their out-of-pocket costs are less, right?

Not necessarily.

That is something that a lot of patients think, but that's not always true. This is a big reason it's important for your dental practice to understand the coordination of benefits and make sure they are filing the claims in proper order. 

DSC05706

In order to file claims in the correct order, you must know which is the patient’s primary and secondary insurance. 

For example, let’s say the patient is covered by two insurance plans because they and their spouse receive insurance benefits from their respective employers. 

The patient’s own insurance plan from THEIR employer would be their primary insurance, and their spouse’s insurance plan would be their secondary insurance. 

Rules of determining the order of insurance benefits

So what if it’s not that simple? What if a parent has a child coming to your dental practice and they are covered by both parents’ respective insurance plans? How can we determine the order of benefits for patients with dual insurance? 

There are many rules to remember when determining the order of benefits, but here are the most common rules used:

1. Birthday Rule

The birthday rule applies when a child has coverage from both parents’ insurance plans. The parent whose birthday falls earlier in the calendar year is primary. Again, age or who’s older doesn’t matter. Whose birthday month falls earlier in the year matters. However, if the parents have the same date of birth, the primary insurance is determined by who has had coverage the longest with the insurance company.

2. Subscriber Rule

The subscriber rule refers to when the patient is the subscriber, employee, member, policyholder of the insurance plan, and he or she is always primary on that plan. Any other plans where the patient is a dependent would be their secondary plan.

3. Medicare Rule

If one of the insurance plans is Medicare, it is typically secondary to the plan covering the patient as a dependent. The vast majority of the time, if a patient is covered by private insurance and a Medicare or Medicaid service, the private insurance is usually the primary. That’s vague and no one likes gray area, but sorry! Insurance loves exceptions. 

Like most government program rules, there are caveats. To remain compliant, our advice is to confirm with your state medicare when verifying benefits. You can learn more about the rules and exceptions of these programs on the Centers for Medicare and Medicaid Services website. 

4. Divorce Rule

The divorce rule applies if a court decree states one of the parents is responsible for the child’s health care expenses/care. The plan of that parent is the primary plan.

This feels like a lot to keep up with, doesn’t it? Well like everything, there’s a reason you should understand coordination of benefits. This knowledge will help you keep your patients happy by properly calculating and understanding their benefits. This way, you can accurately communicate their coverage and out-of-pocket expenses.

Don’t be intimidated by COB rules - coordination of benefits is learnable

Many dental professionals struggle to understand coordination of benefits. Because of this, many offices refuse to accept secondary insurance in their practice.  

Knowing why they exist and their purpose is a great first step in the journey to becoming a pro at insurance rules and regulations.

This is just the beginning of learning about coordination of benefits. There are resources that can help you become an expert, by learning from experts. Continue your coordination of benefits learning journey by signing up for our educational platform, Dental Claims Academy to learn more about how to handle multiple insurance plans from one patient.

join the COB book interest list

Related Posts

Dental billing resources