Pre-Authorization vs. Predetermination

Is your oral surgery practice’s staff managing your dental insurance billing on their own? If so, they may come across different patients who need procedures whose insurance companies require pre-authorization or predetermination. What’s the difference between these two dental insurance terms and the processes they require? Read on to learn how OMS Partners, LLC, easily handles these tasks when you choose medical billing for oral surgeons instead of in-house billing.

Pre-Authorization

Pre-Authorization is a dental insurance billing process in which an insurance company requires you – the oral surgeon – to submit information about the proposed procedure so that they can decide if they will cover the procedure and allow you to secure an authorization/approval. Keep in mind, pre-authorization can take time – between 5 and 30 days depending on the procedure being proposed and the dental insurance provider. It also doesn’t guarantee that the insurance company will pay for the service, which kind of makes the term pre-authorization a misnomer, don’t you think?

Many of the practitioners who choose OMS Partners, LLC for medical billing for oral surgeons do so just because dental insurance companies make pre-authorization such a difficult process to navigate. In order to obtain a pre-authorization on their own, oral surgery practices must:

• Submit the required paperwork
• Record and keep track of a pre-authorization number
• Use the pre-authorization number on any subsequent communications to the dental insurance company
• In the event of a denial due to lack of medical necessity, append the pre-authorization number on your appeal letter

Predetermination

In the world of medical billing for oral surgeons, predetermination means the proposed service can be reviewed for medical necessity, first. Many oral surgery practices like yours prefer predetermination because it’s a process in which the proposed procedure, for example, a tooth extraction, is reviewed for medical necessity, determined to be medically necessary, and your exact payment from the dental insurance company – as well as the patient’s responsibility, if any – will be determined and confirmed before the procedure is performed.

Of course, since predetermination guarantees that a dental insurance company will pay for a tooth extraction, crown, or other oral surgery procedure, the dental insurance company will take longer to send you a predetermination letter. In some cases, it can take between 30 to 45 days – along with very detailed patient information being sent – in order for a dental insurance company to issue you a predetermination letter. And then, of course, there’s all the denials that your in-house billing team must reply to in the event a procedure you know is medically necessary for your patient is initially denied by his or her dental insurance.

Let OMS Partners, LLC Handle All Your Pre-Authorizations and Predeterminations for You

When you choose OMS Partners, LLC for medical billing for oral surgeons, you can trust that we’ll handle all your pre-authorization and predetermination for you, and take these time-consuming processes off your staff’s hands. We’ll also do our best to confirm payments for you through predetermination, so you don’t have to track down payments for expensive procedures from your patients if they initially received a pre-authorization and then their dental insurance changed their mind on paying the claim.

If you have questions about how we can help complicated oral surgery procedures get pre-authorizations and predeterminations through our medical billing services, we’re happy to answer your questions!