assignment of benefits on dental claim

What Is Assignment of Benefits, And How Does It Impact Insurers?

Assignment of Benefits (AOB) is an advantage to policyholders, whereas it presents problems for insurance companies. It is a legal document signed by the policyholder, creating an agreement between the beneficiary and a third party. This agreement transfers control from the beneficiary to the third party, allowing the latter to directly file an insurance claim with the insurer, thus eliminating the need for policyholder involvement.

The Insurance Information Institute considers AOB as a method to settle claims on behalf of a policyholder. After the policyholder signs an AOB, it becomes the third party's responsibility to address the issue and request payment from the insurer for the service provided.

What is the Purpose of AOB?

Once the AOB contractual agreement is signed, it authorizes the third party to submit the claim to the insurance company for the service rendered. This is beneficial for healthcare providers, as it allows them to move insurer reimbursement directly, bypassing the patient. This circumvents potential issues such as underpayments, denials, and appeals, and expedites the process of resolving the issue.

For instance, an out-of-network or non-participating provider, not bound by any legal contract with the insurer regarding service rates, can, upon signing an AOB, submit the insurance claim along with supporting documents, hoping to receive reimbursement at the actual billed charges. In cases where the insurer pays less than the billed charges or refuses to pay the amount, the provider is at liberty to appeal the underpayment or denial.

Services Using AOB:

Services that typically use AOB include:

• Ambulance services,
• Ambulatory Surgical Centre services,
• Clinical diagnostic lab services,
• Biologicals and drugs providers,
• Home dialysis equipment & supplies providers,
• Patients with Medicaid and Medicare plans,
• Services from professionals such as certified nurse anesthetists, Vaccinations,
• Clinical social workers, clinical nurse specialists, nurses, psychologists, and physician assistants.

Impact of AOB on Insurers:

• AOB is garnering negative attention due to the abuse of the practice, leading to inflated claim costs and insurers being charged for services either not performed or unnecessary. Unfortunately, insurers disputing these inflated claims often lose in court. As a result, they incur expenses in paying the plaintiff's attorney, which can be significant. Conversely, if insurers win the case, they are not entitled to any compensation. This situation has led many insurers to settle claims out of court rather than risk litigation.
• The problem with inflated claims and lawsuits is not limited to insurance companies. Patients are also affected, as they face higher insurance premiums and more restricted terms and conditions. This can make it difficult for patients to access the healthcare they need.
• Overall, the issue of AOB abuse is a complex one with far-reaching consequences for both insurers and patients. It is crucial for all parties involved to work together to find a solution that is fair and equitable for everyone.

Impact of AOB on Patients:

Before hiring a third party, it is advisable for patients to get multiple estimates from different companies or contractors to understand the average cost. Moreover, checking for reviews and references before making any decision is crucial. Once a company is chosen, it is vital to read the contract carefully before signing. Having everything in writing, such as the cost, time schedules, payment schedules, and the work scope, helps avoid confusion. It is also essential to review the documents sent to the insurer to prevent the abuse of inflated claim costs.

Overall, Assignment of Benefits (AOB) is an essential tool for healthcare providers and patients, making healthcare management more efficient and less stressful.

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Assignment of Benefits: What You Need to Know

• August 17, 2022
• Steven Schwartzapfel

Insurance can be useful, but dealing with the back-and-forth between insurance companies and contractors, medical specialists, and others can be a time-consuming and ultimately unpleasant experience. You want your medical bills to be paid without having to act as a middleman between your healthcare provider and your insurer.

However, there’s a way you can streamline this process. With an assignment of benefits, you can designate your healthcare provider or any other insurance payout recipient as the go-to party for insurance claims. While this can be convenient, there are certain risks to keep in mind as well.

Below, we’ll explore what an assignment of insurance benefits is (as well as other forms of remediation), how it works, and when you should employ it. For more information, or to learn whether you may have a claim against an insurer, contact Schwartzapfel Lawyers now at 1-516-342-2200 .

What Is an Assignment of Benefits?

An assignment of benefits (AOB) is a legal process through which an insured individual or party signs paperwork that designates another party like a contractor, company, or healthcare provider as their insurance claimant .

Suppose you’re injured in a car accident and need to file a claim with your health insurance company for medical bills and related costs. However, you also need plenty of time to recover. The thought of constantly negotiating between your insurance company, your healthcare provider, and anyone else seems draining and unwelcome.

With an assignment of benefits, you can designate your healthcare provider as your insurance claimant. Then, your healthcare provider can request insurance payouts from your healthcare insurance provider directly.

Through this system, the health insurance provider directly pays your physician or hospital rather than paying you. This means you don’t have to pay your healthcare provider. It’s a streamlined, straightforward way to make sure insurance money gets where it needs to go. It also saves you time and prevents you from having to think about insurance payments unless absolutely necessary.

What Does an Assignment of Benefits Mean?

An AOB means that you designate another party as your insurance claimant. In the above example, that’s your healthcare provider, which could be a physician, hospital, or other organization.

With the assignment of insurance coverage, that healthcare provider can then make a claim for insurance payments directly to your insurance company. The insurance company then pays your healthcare provider directly, and you’re removed as the middleman.

As a bonus, this system sometimes cuts down on your overall costs by eliminating certain service fees. Since there’s only one transaction — the transaction between your healthcare provider and your health insurer — there’s only one set of service fees to contend with. You don’t have to deal with two sets of service fees from first receiving money from your insurance provider, then sending that money to your healthcare provider.

Ultimately, the point of an assignment of benefits is to make things easier for you, your insurer, and anyone else involved in the process.

What Types of Insurance Qualify for an Assignment of Benefits?

Most types of commonly held insurance can work with an assignment of benefits. These insurance types include car insurance, healthcare insurance, homeowners insurance, property insurance, and more.

Note that not all insurance companies allow you to use an assignment of benefits. For an assignment of benefits to work, the potential insurance claimant and the insurance company in question must each sign the paperwork and agree to the arrangement. This prevents fraud (to some extent) and ensures that every party goes into the arrangement with clear expectations.

If your insurance company does not accept assignments of benefits, you’ll have to take care of insurance payments the traditional way. There are many reasons why an insurance company may not accept an assignment of benefits.

To speak with a Schwartzapfel Lawyers expert about this directly, call 1-516-342-2200 for a free consultation today. It will be our privilege to assist you with all your legal questions, needs, and recovery efforts.

Who Uses Assignments of Benefits?

Many providers, services, and contractors use assignments of benefits. It’s often in their interests to accept an assignment of benefits since they can get paid for their work more quickly and make critical decisions without having to consult the insurance policyholder first.

Imagine a circumstance in which a homeowner wants a contractor to add a new room to their property. The contractor knows that the scale of the project could increase or shrink depending on the specifics of the job, the weather, and other factors.

If the homeowner uses an assignment of benefits to give the contractor rights to make insurance claims for the project, that contractor can then:

• Bill the insurer directly for their work. This is beneficial since it ensures that the contractor’s employees get paid promptly and they can purchase the supplies they need.
• Make important decisions to ensure that the project completes on time. For example, a contract can authorize another insurance claim for extra supplies without consulting with the homeowner beforehand, saving time and potentially money in the process.

Practically any company or organization that receives payments from insurance companies may choose to take advantage of an assignment of benefits with you. Example companies and providers include:

• Ambulance services
• Drug and biological companies
• Lab diagnostic services
• Hospitals and medical centers like clinics
• Certified medical professionals such as nurse anesthetists, nurse midwives, clinical psychologists, and others
• Ambulatory surgical center services
• Permanent repair and improvement contractors like carpenters, plumbers, roofers, restoration companies, and others
• Auto repair shops and mechanic organizations

Advantages of Using an Assignment of Benefits

An assignment of benefits can be an advantageous contract to employ, especially if you believe that you’ll need to pay a contractor, healthcare provider, and/or other organization via insurance payouts regularly for the near future.

These benefits include but are not limited to:

• Save time for yourself. Again, imagine a circumstance in which you are hospitalized and have to pay your healthcare provider through your health insurance payouts. If you use an assignment of benefits, you don’t have to make the payments personally or oversee the insurance payouts. Instead, you can focus on resting and recovering.
• Possibly save yourself money in the long run. As noted above, an assignment of benefits can help you circumvent some service fees by limiting the number of transactions or money transfers required to ensure everyone is paid on time.
• Increased peace of mind. Many people don’t like having to constantly think about insurance payouts, contacting their insurance company, or negotiating between insurers and contractors/providers. With an assignment of benefits, you can let your insurance company and a contractor or provider work things out between them, though this can lead to applications later down the road.

Because of these benefits, many recovering individuals, car accident victims, homeowners, and others utilize AOB agreements from time to time.

Risks of Using an Assignment of Benefits

Worth mentioning, too, is that an assignment of benefits does carry certain risks you should be aware of before presenting this contract to your insurance company or a contractor or provider. Remember, an assignment of benefits is a legally binding contract unless it is otherwise dissolved (which is technically possible).

The risks of using an assignment of benefits include:

• You give billing control to your healthcare provider, contractor, or another party. This allows them to bill your insurance company for charges that you might not find necessary. For example, a home improvement contractor might bill a homeowner’s insurance company for an unnecessary material or improvement. The homeowner only finds out after the fact and after all the money has been paid, resulting in a higher premium for their insurance policy or more fees than they expected.
• You allow a contractor or service provider to sue your insurance company if the insurer does not want to pay for a certain service or bill. This can happen if the insurance company and contractor or service provider disagree on one or another billable item. Then, you may be dragged into litigation or arbitration you did not agree to in the first place.
• You may lose track of what your insurance company pays for various services . As such, you could be surprised if your health insurance or other insurance premiums and deductibles increase suddenly.

Given these disadvantages, it’s still wise to keep track of insurance payments even if you choose to use an assignment of benefits. For example, you might request that your insurance company keep you up to date on all billable items a contractor or service provider charges for the duration of your treatment or project.

For more on this and related topic, call Schwartzapfel Lawyers now at 1-516-342-2200 .

How To Make Sure an Assignment of Benefits Is Safe

Even though AOBs do carry potential disadvantages, there are ways to make sure that your chosen contract is safe and legally airtight. First, it’s generally a wise idea to contact knowledgeable legal representatives so they can look over your paperwork and ensure that any given assignment of benefits doesn’t contain any loopholes that could be exploited by a service provider or contractor.

The right lawyer can also make sure that an assignment of benefits is legally binding for your insurance provider. To make sure an assignment of benefits is safe, you should perform the following steps:

• Always check for reviews and references before hiring a contractor or service provider, especially if you plan to use an AOB ahead of time. For example, you should stay away if a contractor has a reputation for abusing insurance claims.
• Always get several estimates for work, repairs, or bills. Then, you can compare the estimated bills and see whether one contractor or service provider is likely to be honest about their charges.
• Get all estimates, payment schedules, and project schedules in writing so you can refer back to them later on.
• Don’t let a service provider or contractor pressure you into hiring them for any reason . If they seem overly excited about getting started, they could be trying to rush things along or get you to sign an AOB so that they can start issuing charges to your insurance company.
• Read your assignment of benefits contract fully. Make sure that there aren’t any legal loopholes that a contractor or service provider can take advantage of. An experienced lawyer can help you draft and sign a beneficial AOB contract.

Can You Sue a Party for Abusing an Assignment of Benefits?

Sometimes. If you believe your assignment of benefits is being abused by a contractor or service provider, you may be able to sue them for breaching your contract or even AOB fraud. However, successfully suing for insurance fraud of any kind is often difficult.

Also, you should remember that a contractor or service provider can sue your insurance company if the insurance carrier decides not to pay them. For example, if your insurer decides that a service provider is engaging in billing scams and no longer wishes to make payouts, this could put you in legal hot water.

If you’re not sure whether you have grounds for a lawsuit, contact Schwartzapfel Lawyers today at 1-516-342-2200 . At no charge, we’ll examine the details of your case and provide you with a consultation. Don’t wait. Call now!

Assignment of Benefits FAQs

Which states allow assignments of benefits.

Every state allows you to offer an assignment of benefits to a contractor and/or insurance company. That means, whether you live in New York, Florida, Arizona, California, or some other state, you can rest assured that AOBs are viable tools to streamline the insurance payout process.

Can You Revoke an Assignment of Benefits?

Yes. There may come a time when you need to revoke an assignment of benefits. This may be because you no longer want the provider or contractor to have control over your insurance claims, or because you want to switch providers/contractors.

To revoke an assignment of benefits agreement, you must notify the assignee (i.e., the new insurance claimant). A legally solid assignment of benefits contract should also include terms and rules for this decision. Once more, it’s usually a wise idea to have an experienced lawyer look over an assignment of benefits contract to make sure you don’t miss these by accident.

Contact Schwartzapfel Lawyers Today

An assignment of benefits is an invaluable tool when you need to streamline the insurance claims process. For example, you can designate your healthcare provider as your primary claimant with an assignment of benefits, allowing them to charge your insurance company directly for healthcare costs.

However, there are also risks associated with an assignment of benefits. If you believe a contractor or healthcare provider is charging your insurance company unfairly, you may need legal representatives. Schwartzapfel Lawyers can help.

As knowledgeable New York attorneys who are well-versed in New York insurance law, we’re ready to assist with any and all litigation needs. For a free case evaluation and consultation, contact Schwartzapfel Lawyers today at 1-516-342-2200 !

Schwartzapfel Lawyers, P.C. | Fighting For You™™

What Is an Insurance Claim? | Experian

What is assignment of benefits, and how does it impact insurers? | Insurance Business Mag

Florida Insurance Ruling Sets Precedent for Assignment of Benefits | Law.com

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Understanding your Explanation of Benefits

What Is an Explanation of Benefits (EOB) statement?

Your Explanation of Benefits (EOB) is a paper or electronic statement provided by your dental insurance company, which breaks down any dental treatments or services that you have received. 

The EOB is different from a bill. It is sent to you after your dentist visit, and outlines your costs , the treatments that were covered under your dental plan, and treatments that may not have been covered and why.

Why Is Your EOB So Important?

After you receive your EOB, you will know what, if anything, you owe to your dentist. An EOB presents the opportunity to make sure you are being billed for a service or treatment you actually received, and that the amounts listed are within your expectations. Therefore, understanding the different parts of an EOB is critical to finding and avoiding billing errors. 

An EOB provides essential information, including but not limited to, treatments performed, dentist’s fees, insurance payments, amount you may owe for deductibles, co-pays, or procedures not covered by your policy, coordination of benefits information (if applicable), the portion of your annual maximum that has been used, and the amounts you have paid toward the deductible in the current benefit year.

An Example of an EOB

Below is an example of an EOB that you will receive after you have visited your dentist. It is important to note that while not every EOB will be formatted the same, this example contains many of the sections and terms you will find on a typical EOB.

How to Read Your Explanation of Benefits

An EOB from Delta Dental will typically include the following information:

• Top of Your EOB: You will see a section that contains subscriber and member identification information, dentist name and the claim number. You might need this information to check on the status of a claim status.
• TH or Tooth No.: This refers to the tooth number(s) treated. This ranges from 1-32 for adults and A through T for children.
• SURF: This identifies the surface of the tooth that was treated. This could include the front side (M: mesial), back side (D: distal) or other areas of a tooth.
• Service Date : The date the procedure was performed.
• Procedure Code: Also referred as the CDT Code (Current Dental Terminology Code), a set of codes used to identify the procedures performed at the dentist’s office.
• Submitted Amount: This is the dollar amount the dentist submitted to your insurance company for a given procedure.
• Approved Amount or Maximum Approved Fee: This is the dollar amount that Delta Dental  approved for the services you received based on the dentist’s agreement with Delta Dental.
• Contract Allowed or Allowed Amount: This amount depends on your employer's contract with Delta Dental, as some employers may place a dollar limit on certain procedures. In most cases, the approved amount and allowed amount will be the same.
• Deductible: The amount you must pay before your insurance benefit begins. 
• % Copay or Payment Level %: The dollar amount or percentage your dental insurance plan will cover per procedure.  Tip: This is different than the flat copay that you typically pay during a physician visit for medical insurnace.  
• Patient/Member Payment: The patient/member payment is the dollar amount you pay.
• Delta Dental Payment : Delta Dental’s payment for the services provided.
• Reference Code, Adjustment Notice or Process Policies :  Explains any limitation on your insurance coverage for the procedure you received.  

Other Terms That Your EOB Might Reference

These terms will not always be used in your Explanation of Benefits, but it is important to know their meaning in case they appear.

• Procedure Description : Describes the treatments and procedures you received at the dentist’s office.
• Fee Adjustment:  The difference between the approved amount and the submitted amount.
• Claim Number:  The number assigned to the claim that corresponds to the EOB.
• Your Other Insurance Paid:  The amount paid by any other insurance you may have.
• Benefit Period:  The period of time of your coverage. 
• Annual Maximum : The maximum dollar amount your dental insurance will pay toward the cost of dental services and treatment .  Tip:  This is not the most you will pay out of pocket per year that you typically see in medical insurance  plans.
• Annual Maximum Used to Date:  The amount of your plan maximum used to date during a benefit period. 
• Overmax:  The amount which exceeds your plan maximum during a given benefit period.

Frequently Asked Questions About Explanation of Benefits

Here are the answers to common questions about EOBs.

• Is my explanation of benefits a bill?

No, an EOB is  not  a bill. On the most basic level, your EOB will provide a breakdown of the dental services that you received, the amount Delta Dental will pay to your dentist, and any portion you will be expected to pay the dental office.  A bill for any amounts you may owe will come separately.

• When will I receive my EOB?

The dentist will bill your dental insurance company after you’ve received dental treatment, and then you will receive an EOB, typically before you receive a bill from the dental office for any amount you may owe.

• How can I stop paper EOBs?

Please contact  your local Delta Dental  to manage your Delta Dental benefits. On your local Delta Dental web portal, you can view plan information, download forms, view claims, track dental activity and go paperless!

Additional Resources

Looking for more information? Brush up on some of the dental insurance basics:

• Dental Insurance Words You Need to Know
• The Basics of Dental Benefits
• Why Dental Insurance Is Worth It

If you have additional questions or require further support, connect with  your local Delta Dental.

This article was developed jointly by  Delta Dental Plans Association  ,  Delta Dental of Arizona  and  Delta Dental of Wisconsin .

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Assignment of benefits: an alternative to joining a network.

Question: I graduated from dental school last year and am now working as an associate in an established practice. Because I was not able to join the Delta Dental Premier network prior to Aug. 1, 2014, the fees I would be paid for services provided to Delta Dental Premier patients are about 20 percent less than what my employer is paid for the same services. Our practice has a significant number of Delta Dental Premier patients. I have been doing some research and read about using an assignment of benefits as a way to be paid by a dental plan for my services without having to join its network. Can you explain this?

Answer: If accepted by the dental plan/insurer — and this is far from certain, as explained below — an assignment of benefits results in the dental plan/insurer paying you the benefit available to your patient for the service you have provided and, since you have no contract with the dental plan/insurer, you being able to bill and collect the balance of your fee from the patient.

An “assignment of benefits” is a written document signed by a patient stating that the patient has agreed to assign his or her dental plan/insurance benefits to a dentist in consideration for the dentist’s services. The dentist files the assignment of benefits form with the claim for payment and any other required documentation with the dental plan/insurer. If accepted by the dental plan/insurer, the dentist is paid directly the amount of the bene-fit available to the patient for the service provided. The dentist is free to bill and collect the difference between the benefit received from the dental plan/insurer and the dentist’s fee for the service (if higher) directly from the patient. Typically, the dental plan/insurer will issue an explanation of benefit document to both the dentist and the patient setting forth the amount of the dentist’s fee for the service, the amount of benefit paid to the dentist, and the balance owed by the patient.

Using an assignment of benefits would be a very workable solution, allowing collection of most of the fee from the dental plan/insurer and operating free of restrictions on fees and balance billing. However, there are two problems.

First, dental plan/insurers typically refuse to accept assignments of benefits because doing so means (a) they lose control of fees collected by dentists and (b) dentists then have little incentive to join their networks (where control of fees and many other aspects of practice are obtained).

There have been attempts to address this first problem legislatively.  Several states have enacted laws requiring dental plans/insurers to accept assignment of benefits.  Michigan, unfortunately, does not have a law requiring dental plans/insurers to accept an assignment of benefits.  In the absence of such a law, Delta Dental and other dental plans/insurers operating in Michigan are free not to accept assignments of benefits.

The second problem is that even if a state has enacted a law requiring dental plans/insurers to accept assignments of benefits, federal law may make enforcement of the state law illegal. The Employee Retirement Income Security Act (“ERISA”) is federal law that, among other things, regulates employee benefit plans. If a patient’s dental benefits or insurance are provided by an employee benefit plan, then ERISA controls. ERISA contains a preemption provision that has the effect of not allowing the states to enforce any of their laws that regulate employee benefit plans. Whether a statute requiring a dental plan/insurer to accept an assignment of benefits would be preempted by ERISA and therefore unenforceable in Michigan is an open question.  There is currently a split on this question in the federal appellate courts, with the majority holding that ERISA does preempt state laws requiring acceptance or assignment of benefits.

Therefore, until Michigan enacts a statute requiring acceptance of an assignment of benefits and the preemption question is answered once and for all (or ERISA is amended to not preempt state laws requiring acceptance of assignments of benefits), assignment of benefits will not be a perfect solution.

NOTE: This column is the opinion of the author and does not constitute legal advice from the Michigan Dental Association.

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Dentrix Features For Filing and Following Up on Insurance Claims

File claims accurately and completely to get them paid as quickly as possible and maintain healthy cash flow. .

If your practice accepts the assignment of benefits from your patients’ dental insurance, it’s critical to file claims in a timely manner and maintain an efficient follow-up system for those claims in order to keep a healthy cash flow. There are several tools in Dentrix that you can use to help you file claims that contain all the necessary information. That way claims are paid the first time they are filed without the insurance company requesting additional information, which can cause costly delays in claim payments.

One helpful tool is Automatic eClaims Attachments . This useful feature automatically includes required eClaim attachments for certain procedures and warns you if the required attachments can’t be found. This helps to solve the problem of forgetting to attach necessary information that the insurance may require to pay a claim, for example an X-ray or a narrative.

To help you out, by default Dentrix comes loaded with several common requirements for procedure codes for each insurance company, but you can also add your own custom requirements for procedure codes as you learn which information insurance companies are asking for.

With Automatic eClaims Attachments, if an insurance company requires an X-ray and a narrative for a D2940 crown code, Dentrix will recognize that requirement based on the procedure code and, if available, automatically add the needed attachments to the claim for you. This ensures that claims will not be sent without the necessary documentation and therefore paid in a timely manner.

You can keep track of where claims are in the payment process by generating an Insurance Aging Report. The Insurance Aging Report allows you to view which claims are current and which are over 30 60, or 90 days. Information on the report is listed first by insurance carrier, and then by patient. You can also easily see the date that claims were sent. Ideally no claim should be over 60 days past due, so you can focus on those accounts first. The Insurance Aging Report should be generated and worked through on a regular basis, at least monthly or perhaps more frequently based on the number of outstanding claims you have in your office. Contact each carrier to follow up on what may be causing the delay in payment.

After generating the Insurance Aging Report and contacting the insurance company to follow up on claims, use the Claim Status Notes to record the status of each claim. For example, if a claim is pending or requires additional information, update the claims status note with relevant information so everyone in the office is aware of what’s happening with the claim and why it hasn’t been paid yet. Additionally, when you generate the Insurance Aging Report you have the option to view the claim status notes on the report. This is beneficial because you can easily see if you just checked on the status of an insurance claim and, if so, immediately move on to the next claim on the list.

Insurance payments make up a large portion of the accounts receivable for many dental practices, so it’s important to file claims accurately and completely to get them paid as quickly as possible and maintain healthy cash flow. Try using these features in Dentrix to file insurance claims with all the necessary attachments and follow up on outstanding claims regularly.

For additional information, read the following :

• Add Required Attachments to Claims Automatically
• Find the Information You Need on the Insurance Aging Report
• Claim Status Notes

By Charlotte Skaggs Certified Dentrix Trainer and The Dentrix Office Manager columnist

Charlotte Skaggs is the founder of Vector Dental Consulting LLC, a practice management firm focused on taking offices to the next level. Charlotte co-owned and managed a successful dental practice with her husband for 17 years. She has a unique approach to consulting based on the perspective of a practice owner. Charlotte has been using Dentrix for over 20 years and is a certified Dentrix trainer. Contact Charlotte at [email protected] .

• March 16, 2023
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