Top Five Tips and Traps When Processing Predetermination
Sandie Baillargeon Posted on July 4th, 2018


Insurance companies will use many different tactics to slow the payment of the claim and to prevent the claim be paid at all. The psychology behind the predetermination process is such that if the patient has to wait for four to six weeks, he/she is most likely to not follow through with the treatment. This is especially true if there is an out of pocket expense to the patient. Insurance underwriters include the predetermination requirement in the insurance policy in order to deliberately discourage the subscriber from having the treatment that he/she needs.

These tactics are deliberate attempts to keep the money in the hands of the insurance companies. Insurance companies are in business to make large profits and they do not care about your patient’s health. Dental insurance is considered a living benefit, which means that if a subscriber has dental insurance, they are most likely going to use their benefit. This differs from most indemnity based insurance plans that only pay out a claim based on catastrophic loss or death. So the insurance companies must find specific ways to slow down the frequency of payments going out while continuing to collect high premiums from employers. How they do that is by including a predetermination process, having a missing tooth exclusion clause, limiting the frequency of coverage for emergency exams, continuing care appointments, scaling units, annual maximums and deductibles, copayments, and anything else that they can impose limits on.

Insurance adjudicators will do everything necessary to decrease the utlization rate of the insurance plan. The simple logic behind it is the more money that flows in from employer premiums and the less that is paid out in claims, the higher the profit margin for the insurance companies.

Many dental conditions are asymptomatic and if the patient is not in pain, he/she is not compelled to move forward with the treatment that they need. If the patient has to wait for four weeks after receiving the diagnosis and treatment plan to see if their insurance company “approves” , the patient is less likely to complete the treatment, but at the very least, payment of the claim has been slowed down considerably, leaving more money in the hands of the insurance company.


1. Allowing the patient to think that the treatment is not needed unless the insurance company approves.

2. Sending the predetermination by snail mail only

3. Assuming that you will receive an answer from the insurance company

4. Assuming that the patient will contact you immediately

5. Not staying in touch with the patient during the lag time

Your dentist is overcharging


1. Send the predetermination by EDI and by snail mail simaultaneously. Include the estimated lab fee and let the patient know that whatever percentage th

2. Manage the patients expectations. Contact the patient one to two weeks after the predetermination has been sent.

3. Include as much information as possible, i.e. date of the extraction, what other teeth are missing in the arch, initial placement, etc. Send a cover sheet that includes that information. For a sample cover sheet, send me an email at with the subject line “cover sheet”.

4. Schedule the appointment 3 – 4 weeks after sending the predetermination. This hels the patient to understand that the treatemnt is still required. Make financial arrangements with the patient.

5. Send a letter of appeal and look at any of the alternative benefits. Clearly explain to the patient what the alternative benefits clause means and

You are your patient’s advocate because you really do care about your patient’s health. Insurance companies only care about profit and your patient is only a number to them. As dental professionals, it is our job to assist our patients in understanding their benefit and helping them to receive the reimbursement for what the benefits that they deserve and have paid for. Don’t let insurance companies manipulate your patients and interfere with their care and the doctor patient relationship. Follow the tips in this article and most importantly, stay in touch with your patient during the lag time. Dealing with dental insurance benefits is a reality for all dental offices. Understanding their tactics and knowing how to avoid the traps will help you to assist your patients and increase the case acceptance at your office.

Author: Sandie Baillargeon


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