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What is a dental insurance waiting period?

June 18th, 2021 | 5 min. read

What is a dental insurance waiting period? Blog Feature

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As a dental professional, your job is to understand the ins and outs of all things dental… but no one ever told you that you also need to know about the rules of dental insurance

Insurance makes submitting claims complicated for a reason… Insurance companies know it’s not a fun thing to learn about! A dental insurance plan waiting period is just one example of a fine-print insurance limitation that can delay patient treatment acceptance and in turn, affect your overall revenue. 

Our job at Dental ClaimSupport is to deal with insurance so that dental practices like yours don’t have to. Needless to say, we know a lot about insurance because we communicate with insurance representatives every day! 

In this article, we want to share with you why you should understand dental insurance waiting periods and how they negatively impact your reputation, patients, and/or pile up in unpaid patient balances.

So, what exactly is a dental insurance waiting period? 

All dental benefit plans include exclusions and limitations. One of those limitations can be a waiting period. While dental plan limitations and exclusions do not affect how you document and report procedures rendered, you should be aware of common limitations such as waiting periods. 

In dentistry, an insurance waiting period is a stipulated time frame per insurance policy and patient that will not allow benefits for certain procedures until a set amount of time has passed. A typical waiting period for a policy would be 6 months for basic procedures (fillings, SRPs, etc) and 1 year for major services (crowns, bridges, implants, etc). 

For example, say a patient's insurance plan starts January 1, 2021, and has a waiting period attached for major services of one year. So no benefits would be payable by the insurance for any major service until January 2, 2022. Annoying right?

A waiting period and the allotted time is defined by the employer plan, or the insurance company when the plan is purchased directly from the insurance payer.

Why is this a limitation, you might ask? 

Well, to be frank, waiting periods have been around awhile, but companies also have to consider risk management. They don’t want to be taken advantage of by employees. Employers are reducing benefits offered and one of those is the dental benefits. Patients without a dental benefit plan offered by their employer are electing to purchase individual or family plans directly from the insurance payer or through their state insurance marketplace. 

Some people only want the insurance for a limited time, because they need new dentures or a bunch of implants placed… AKA major procedures. They have a $3,000, calendar year maximum, so they could essentially get a job with insurance or purchase an individual plan, have the insurance, spend three grand, and then quit the job and move on. Insurance companies know this, therefore things like waiting periods protect them from these situations.

Not every insurance plan has waiting periods, but many do. Waiting periods are means of controlling how much insurance money a patient can receive in benefit reimbursement in a predefined period of time of being effective with the plan. This keeps insurance costs down for employers and payers, alike.

Waiting periods are usually in the “fine print”, so it’s important when you’re getting an insurance breakdown during verification to ask if a patient has a waiting period.

To learn more basic dental billing terminology, check out our Learning Center

How do dental insurance waiting periods affect my practice's revenue?

So, why should you ask about insurance waiting periods when verifying patient insurance? How does this affect your practice? The answer is pretty simple.

If either party, the patient or the dentist is unaware of the waiting period, and the procedure is not reimbursed by insurance, the patient is going to have to pay out of pocket. If this is a surprise they did not budget for, we can pretty much guarantee the patient will be unhappy. 

Although it's the patient's responsibility to know their benefits, typically the office does the leg work as a courtesy to try and give patients close estimates to what their treatment will cost. The more a patient knows what they'll owe, the more likely they'll be to schedule. Hence why they get upset when they get a bill they were not expecting due to a waiting period

For example, say whoever verifies insurance doesn't know about the waiting period, and they tell a patient “you need a crown” and crowns are covered at 50%. Everyone anticipates 50% of the crown to be covered by insurance but because of the waiting period, nothing is paid by insurance. Nope! The patient is then sent a bill that is twice the amount they were expecting. You’d be angry too if you were in their shoes! 

Have you ever had a patient who got a bill that was bigger than they were expecting? Well, insurance is definitely not going to negotiate a different price with you… we will know this. And if the patient simply cannot pay it, they won’t. 

Surprise dental insurance plan waiting periods can hinder your practice from being paid for the work you performed.

How do you avoid losing money due to dental plan waiting periods?

When you are verifying insurance for a patient's dental visit, it should be a top priority to ask the insurance company if the patient has a waiting period on their policy. If they do, you should directly contact the patient BEFORE their procedure, and inform them that insurance will not pay for the particular procedure. 

If you don’t, and when insurance doesn’t pay for the procedure, the patient is inclined to blame you, and not the insurance company for the oversight. This could lead to upset patients and potentially lost revenue.

Is it fair? Not really, but that doesn’t matter. You need to be proactive instead of reactive.

Insurance companies make their policies difficult for patients to understand. Your patient ultimately relies on you to inform them of the ins and outs of their policy. But you can use this to your advantage. 

We now know some procedures may not be paid due to a waiting period, however PPO providers still have to honor the PPO discount, according to your contract.

For example, if a patient received a crown for $1,000 and the PPO in-network fee is $700, the provider can only charge that patient $700 for the procedure. This is a $300 discount to the patient. You being savvy and explaining the $300 discount, will most likely get the patient to accept treatment. 

Do not skip steps when verifying patient dental insurance

You should have someone fully trained on your dental team to verify the patient's insurance. It’s a relatively straight-forward task, but this person should know all of the questions to ask, like “is there a waiting period on this patient’s insurance policy?” to avoid not being paid. 

Insurance is messy and complicated. So staying up-to-date on what kind of information your practice should obtain when verifying insurance is key. To learn more about how to understand insurance limitations and rules, check out our educational resource, Dental Claims Academy

Here, we help dental professionals like yourself navigate the complexities of insurance, CDT codes, and other administrative nuances that you may not have learned in dental school. 

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