09.15.06 - Issue # 236 Forward This Newsletter To A Colleague

“My Insurance Pays for Cosmetic Teeth Whitening”
Navigating the River of Insurance Reimbursement


Belle DuCharme CDPMA
Instructor/Consultant
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I have a laminated copy of a check from a well-known dental insurance company (name I will not disclose) for the amount of twenty-seven thousand five hundred dollars ($27,500.00).  I keep this as evidence to demonstrate to my patients that insurance companies do make errors.  The check amount was supposed to be $275.00 as payment in full for a home teeth-whitening kit.   The fact that the insurance company covered the whitening was impressive enough without the error in payment.  After all, we have been told that insurance companies do not pay for cosmetic procedures.  This is a blanket statement that needs to be qualified to say, “most insurance plans do not have benefits for cosmetic services.”  We are now in the age of the “designer” dental benefit plans that defy explanation, especially the plans that cover one prophy in a calendar year.  Remember that the employer draws up these plans with benefit provider based upon costs.  When claims are submitted they are administered per contract not by dental necessity.

Maximizing a patient’s benefits for a calendar or contact year is not much of a challenge since the benefit years’ maximums have not gone up in thirty or more years.  If you are a contracted PPO provider you will find that you can do more dentistry yet get reimbursed for less because you are subject to write-offs (if you bill out UCR fees). 

Often the question is asked, “Can I charge more for a procedure than the PPO fee schedule allows?”  I have spent some time researching this question and the most popular answer is NO.  However there are some gray areas that need to be addressed.  As I have said in other articles, “If you are going to play the PPO game then you better know the rules of reimbursement for each plan you are signed up to accept.”

You need to know if the procedure you are planning to do is covered by the plan.  If not, then you can charge your UCR fee unless there is a clause in your agreement that states you must “discount your fee by 15%”.  It could be anywhere from 10 to 25% but I use 15% as an example.  If it is covered by the plan but the reimbursement amount is sadly low then you need to look at the costs involved in producing the item. For instance, an insurance company (I won’t disclose the name) reimburses 50% of $392.00(this is a real contract fee) for each Porcelain lab produced veneer. The lab fee is almost $200.00 for each veneer because you use the best lab and you are certain of a good result. Your UCR fee for this veneer is $1100.00 each.  The PPO contract says that you must accept as payment in full the contracted fee and not charge the patient the difference. “ARGHHH,” I realize that dentist fees and lab fees differ from state to state but some insurance company fee schedules don’t.

Looking at this scenario you cannot produce the product for the amount of money you will be reimbursed.  Your options are: 1. Not to offer the service and refer the contracted patient out of the office 2. Find a cheaper lab, and explain to the patient that the result may not be the best 3. Explain to the patient about the situation and say that you cannot provide Porcelain laminate Z but you can provide Porcelain laminate X for $200.00 each more because you need to use Lab Q for the best result and let the patient decide what they want to do.

Understanding “alternate benefit” rules are important to getting reimbursed.  If a procedure is not a covered benefit, the patient pays out of pocket at UCR rate.  Sometimes there is an alternate benefit, such as composite restorations that are often downgraded to amalgam.  If you do not provide amalgam then you can upgrade to the composite fee and the patient pays the difference.  Always explain to the patient that the insurance covers the cost of amalgam on posterior teeth and you are placing composite or (white fillings) instead.

Insurance billing and reimbursement is a large segment of the Advanced Training Course for Front Office Dental Employees offered by McKenzie Management.  The benefit to you is that we customize your training to fit your needs.  We look at whether you are a contracted PPO provider, accept PPO assignment with patient share of costs or both, and with our resources help you to achieve a higher level of success in your practice.  Join us today and enrich your knowledge for a more profitable practice.

For more information on McKenzie's Advanced Training for Front Office, Office Managers or Dentists email training@mckenziemgmt.com, call 1-877-777-6151 or visit our web-site at http://www.mckenziemgmt.com/.

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