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When patients are covered by more than one dental insurance plan, such as their own and a spouse’s, it can create unexpected complications in the billing process. A common source of confusion is a clause called non-duplication of benefits. While the term comes up often, its implications for claim processing aren’t always clear. For dental professionals, understanding how this clause works is necessary for accurate estimates, smoother insurance coordination, and helping patients avoid surprise balances. In this article, we’ll break down what non-duplication of benefits means, how it influences reimbursements, and what to consider when handling secondary insurance claims.
Apr 25, 2025
About Dual Coverage and Coordination of Benefits (COB)
Dual coverage occurs when a patient has more than one dental insurance plan, often through both their employer and their spouse’s, or from multiple jobs. While it can offer broader protection, it also adds complexity to claim processing.
Coordination of Benefits (COB) is the process insurers use to determine which plan pays first (primary) and which pays second (secondary). The goal is to avoid duplicate payments while maximizing the patient's coverage.
Here’s how insurers typically decide the order:
For children, the birthday rule applies: the parent whose birthday (month and day) falls earlier in the year provides the primary plan.
For adults, the plan from the patient’s employer is usually primary.
Active employment plans take priority over COBRA or retiree coverage.
If no other rules apply, the plan held longer is considered primary.
It’s important to note that dual coverage doesn’t mean double benefits. COB helps plans work together, but some include clauses, like non-duplication of benefits, that can limit what the secondary plan pays.
For dental professionals, especially those working across multiple practices, understanding COB rules supports accurate billing and clearer patient communication. Because provisions vary, it’s always worth confirming with each insurer when dealing with dual coverage.
About Non-Duplication of Benefits
Non-duplication of benefits is a clause found in some dual insurance scenarios, typically in self-funded dental plans, where the secondary insurer pays nothing if the primary plan covers at least as much as it would have paid. While standard Coordination of Benefits (COB) is designed to maximize patient coverage, non-duplication does the opposite: it limits the secondary plan’s liability, often resulting in higher out-of-pocket costs for patients.
For example, a procedure costs $100. The primary plan covers $80 (80%). The secondary plan also has an 80% coverage rate.
With standard COB, the secondary plan pays the remaining $20.
With non-duplication, the secondary pays nothing, because the primary already paid what the secondary would have.
Why it matters:
This clause often catches both patients and front office teams off guard. Patients assume two plans mean better coverage, but with non-duplication, the secondary plan may offer little to no additional value. These clauses are common in self-funded employer plans, which fall under ERISA, exempting them from many state insurance regulations and making them harder to predict or standardize.
Differences between Non-Duplication and Standard COB:
Payout structure: Non-duplication only contributes if its benefit exceeds that of the primary. Standard COB fills in the remaining balance up to 100%.
Patient responsibility: Non-duplication often results in higher out-of-pocket costs. Standard COB typically reduces them.
Plan types: Non-duplication is more common in self-funded plans. Standard COB appears across a wider range of group insurance policies.
Intent: Non-duplication protects the insurer’s bottom line. Standard COB focuses on optimizing patient benefits without overpaying.
Hypothetical Scenarios: How Non-Duplication of Benefits Affects Patients
Let's look at some real-world examples to see how non-duplication of benefits clauses affect people with dual coverage.
Scenario 1: Both Plans Cover at the Same Rate
A patient needs a cleaning that costs $150. Their primary plan covers cleanings at 80%, and their secondary plan also covers 80% but has a non-duplication of benefits clause.
Primary plan pays: $120 (80% of $150)
Secondary plan would normally pay: $120 (80% of $150)
With non-duplication of benefits, the secondary plan pays: $0
Patient pays: $30
The patient might be shocked that having two insurance plans still leaves them with a bill. Despite both plans offering 80% coverage, the non-duplication of benefits clause blocks the secondary plan from helping, leaving the patient to pay the difference.
Scenario 2: Primary Plan Covers Less Than Secondary Would
A patient needs a $100 filling. Their primary plan covers 50%, while their secondary would cover 80% if it were primary.
Primary plan pays: $50 (50% of $100)
Secondary plan would usually pay: $80 (80% of $100)
With non-duplication of benefits, the secondary plan pays: $30 (the difference between what the primary paid and what the secondary would have paid as primary)
Patient pays: $20
Here, the patient does benefit somewhat from dual coverage, as the secondary plan fills part of the gap. But they still pay out of pocket due to the non-duplication clause limiting the secondary plan's contribution.
Scenario 3: Impact on Dental Professionals with Multiple Coverage Sources
A dental hygienist working at multiple practices has coverage from two sources: their primary through their employer and a secondary plan through their spouse.
They need a major dental procedure costing $1,000. Their primary plan covers 60%, while the secondary would cover 70% if the primary, but has a non-duplication of benefits clause.
Primary plan pays: $600 (60% of $1,000)
Secondary plan would normally pay: $700 (70% of $1,000)
With non-duplication of benefits, the secondary plan pays: $100 (the difference between the primary payment and what the secondary would have paid)
Patient pays: $300
This shows how even dental professionals face significant costs despite dual coverage.
Dental practices should explain these complex situations clearly, perhaps using visual breakdowns of projected costs. Patients should review both insurance policies carefully and discuss potential costs with their dentist before treatment.
Be transparent about how non-duplication of benefits works to help patients make informed decisions about care and costs, which can reduce surprise bills and disputes later.
Why Do Insurance Plans Include Non-Duplication of Benefits Clauses?
Insurance plans include non-duplication of benefits clauses to control costs and manage risk. These provisions stop insurance overpayment when a patient has multiple coverage sources, keeping premiums lower for everyone.
From the insurer's view, these clauses serve several purposes:
Cost control: They limit payouts when a primary plan has already covered most expenses, reducing their financial exposure.
Risk management: These provisions help insurers better predict and control their potential liabilities.
Preventing over-utilization: The clauses stop patients from potentially profiting from multiple coverages, which might otherwise encourage unnecessary services.
Different stakeholders feel different effects:
Employers can offer dental benefits at lower premium costs.
Insurance providers simplify claim processing and reduce payouts, which can potentially improve their profits.
Patients may face unexpected costs despite having dual coverage, but they may benefit from lower premiums overall.
Some states have taken action against these clauses. California has banned non-duplication of benefits clauses in dental plans, as noted by the American Dental Association. This helps patients maximize benefits and reduce out-of-pocket expenses.
The regulatory concept tends to be complicated, though. Self-funded plans governed by ERISA may be exempt from state regulations. This means even in states that restrict non-duplication clauses, patients might still encounter them.
How to Manage Non-Duplication of Benefits
Dental offices can manage non-duplication of benefits clauses effectively while keeping patients happy. Here's how:
Educate and Train Staff
Make sure your front-office team understands the coordination of benefits (COB) and non-duplication of benefits clauses thoroughly. Hold regular training on identifying primary and secondary plans, processing claims, and reading Explanation of Benefits (EOB) statements. Provide staff with reference guides for different COB scenarios to increase accuracy.
Proactive Communication with Patients
Explain insurance coverage and non-duplication of benefits clearly from the start. During first appointments or financial consultations, use visual aids like diagrams to show how non-duplication affects coverage and potential costs. Give patients written cost breakdowns, noting that actual amounts may vary due to insurance details and other factors.
Verify Insurance Coverage in Advance
Contact both insurers to verify benefits and check for non-duplication clauses before submitting claims. This prevents surprises later. Document all verification calls with the representative's name and details to resolve any future disputes.
Submit Claims Correctly
Bill the full fee to both insurance companies, adjusting for contracted rates only after receiving the payments. If a secondary plan denies a claim due to non-duplication, explain the reason to the patient in writing.
Use Transparent Billing Practices
Clearly mark on patient statements when secondary plans don't pay due to non-duplication of benefits. Include explanatory notes to prevent confusion. Provide itemized invoices showing coverage from each insurance and the remaining patient balance.
Offer Financial Alternatives
When patients face unexpected costs due to non-duplication of benefits, offer payment plans or financing options to help manage expenses.
Partner with Insurance Experts
Consider working with dental billing services or consultants who specialize in COB and secondary insurance. These experts can optimize claims and reduce errors.
Keep in mind that the goal is to provide clarity and support to patients while managing insurance complexities. This helps dental practices maintain strong patient relationships and a positive community reputation.
Help Your Patients and Your Team Navigate Dual Coverage
Understanding non-duplication of benefits is important for dental professionals managing patients with dual insurance coverage. These clauses can influence reimbursement amounts, patient out-of-pocket expenses, and the organization of your billing processes. By educating your team, verifying benefits in advance, and communicating transparently with patients, you can minimize confusion.
Need extra hands at your practice? Give Teero a try or give us a call to find qualified dental professionals when you need them.