Helpful Information from the ADA Council on Dental Benefit Programs
Always Report Your Full Fee On Claims
Dentists should always report their full fee for the procedure code on the claim form, regardless of what the benefit amount is. Te full fee represents the costs of providing the service and the value of the dentist’s professional judgment in providing the service. As dentists determine their fees for services rendered, the full fee could be any amount, beginning with zero dollars (i.e., $0.00). A $0.00 report on a claim form is a valid entry. A contractual relationship with any payer does not change the dentist’s full fee. For example, dentists in a payers’ network agree to offer a discount and sometimes agree to additional processing policies that might stipulate a “least alternative benefit” or “bundling” that a service might be benefitted against. A common policy includes combining separate DO and MO restorations on a single tooth and paying for a single MOD. Tis is simply the payers’ benefit policy and should not influence your treatment plan. When this occurs the payer’s EOB must clearly explain how the dental benefit plan’s provisions affected the payment amount. Te explanation must not suggest to a patient that the treatment was somehow incorrect or unnecessary. Patient education prior to treatment in such instances is key to practice success. It is likewise important that the dentist does not report a full fee that is artificially inflated over what she usually expects to collect, when no benefit is involved. If the fee collected for a given procedure is never more than $90, then the dentist should not report a full fee of $100. Te ADA Code of Ethics says that “Te fee for a patient without dental benefits shall be considered a dentist’s full fee. Tis is the fee that should be represented to all benefit carriers regardless of any negotiated fee discount.” Over time,
fees reported to the plan on claim forms are used to monitor trends and serve as the basis for the payer setting allowable amounts for the area. Tese analyses will not reflect the true market trends if the dentists in that area aren’t submitting their full fees. Coordination of benefits is also dependent upon the fee reported on the claim form. A dental plan administers a “benefit” to the patient and is not intended to cover all charges. If you bill your full fee the patient will receive the maximum benefit from his/her plan. CDT Code and claim submission assistance is available from the ADA.
Assistance is also available when there are issues with a third-party payer. Please call 800-621-8099 or send an email to
dentalbenefits@ada.org.
Payers Using Credit/Debit Cards for Payment
It is not uncommon today for dental benefit carriers and third party administrators (TPAs) to pay dental offices with a credit/debit card instead of the traditional paper check. In fact, this trend seems to be more popular with TPAs than it is with traditional dental plan carriers and has created concerns for dental offices. VPay is an example of a company that provides this service and offers a virtual stored- value debit card program designed specifically for claims payments. VPay is delivered to the dental office either by fax or secure email. Te dental office can process the payment just like it does any other credit card
transaction – by entering the card number, security code, expiration date and amount. VPay touts quicker reimbursement as an advantage to using the stored-value card; however, dentists have reported that the card may carry a higher processing fee than a traditional debit or credit card transaction. You do not have to accept the stored-value card as payment if you do not wish to do so. You can request to opt out of using the stored- value card and instead receive a check as payment for services rendered. If that is your choice, you should call the toll-free number provided on the explanation of benefits (EOB) statement which accompanies the stored-value card and inform VPay or the issuing company that a check is preferred. Te ADA has received reports from some dentists indicating that some of these companies’ customer service representatives are reluctant to waive the stored-value card as payment; thus, you may have to escalate your request to a company supervisor or manager. Te ADA’s Council on Dental Benefit Programs (CDBP) recommends dentists carefully read the fine print accompanying EOB statements and suggests that members call CDBP staff at 800-621-8099 for additional assistance.
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