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10.10.08 Issue #344 Forward This Newsletter To A Colleague

Angie Stone RDH, BS
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To Alternate Or Not To Alternate? That Is The Question.

A common practice in hygiene departments across the country is to alternate charging a patient for a prophy appointment and a periodontal maintenance visit. In many instances, the office will charge out a prophy procedure two times per year and periodontal maintenance two times a year when the patient has had active periodontal therapy. This method of billing is incorrect due to misuse of the ADA procedure code and could be considered fraudulent if codes are altered specifically to get insurance benefits.

The reason offices have adopted this system is because many insurance plans will not pay for more than two periodontal maintenance visits per year. They have discovered that if standard prophys are billed in between periodontal maintenance visits that some insurance policies will pay for all four. Although this is advantageous for the patient, it is a losing situation for the dental practice. The patient is receiving a service 4 times a year and two of the visits are charged out at a lesser fee. I believe it is fair to say that there is not another medical profession that will downgrade the price of a provided service in order to have the patient receive insurance benefit.

Over years of doing this favor for patients, dental practices have conditioned patients to expect this behavior. When the office attempts to change protocol existing patients get upset that they are being charged more, which they don’t understand because the service has not changed. It is now the responsibility of dental practices to turn this procedure around and educate patients as to why this is not correct. So, how do we do that?

The first step is to stop billing insurance plans in this fashion immediately. People who have not experienced this billing routine will not know the difference and therefore will not be disturbed. Those who have been billed this way may be upset.

The response given to those patients is, “We have recently been re-educated regarding the billing of hygiene services that are provided after a patient has undergone active treatment for periodontal disease. We are no longer allowed to adjust the fees as we have in the past. We are sorry for any inconvenience this may cause you; however, we need to follow correct billing protocol. ” The office may even consider sending a letter from the doctor to patients who have been allowed to pay for services this way. That way the issue is addressed with every patient at one time.

If we review the description of a prophylaxis and a periodontal maintenance procedure, we see the two are very different from each other. According to the current CDT, a prophy consists of removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritation factors.

The CDT states that a periodontal maintenance procedure is instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site-specific scaling and root planing where indicated, and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered. A patient who has undergone active periodontal therapy is no longer a candidate for a prophy.

A prophy, as defined, will not provide the necessary preventive care this patient requires. Therefore it is in the best interest of the patient to receive periodontal maintenance at each and every hygiene visit.

Given these descriptors it is obvious that a periodontal maintenance appointment involves much more than a prophy, hence the larger fee. If the fees are alternated each time, the patient is getting a more involved service 4 times a year and only paying full price for 2 of the visits. If we do a little math here, we can see how this may affect hygiene production.

Let’s say that the office fee for a prophy is $80 and the fee for a periodontal maintenance is $110. The patient will be charged $380 for professional hygiene services annually if the fees are alternated. If they were not alternated, the annual fee would be $440. This is only $60 per year more for the patient to pay if their insurance does not cover those treatments. However, if the office has an active patient base of 1,000 patients and we say that statistically at least 1/3 of those should have perio maintenance, that dollar amount is going to be fairly large. 300 patients paying $60 more per year would bring in $18,000 in production for the hygiene department.

If nothing I said earlier in the article would persuade your office to stop the practice of alternating prophys and periodontal maintenance, maybe the numbers will.

Need help with implementing new systems in your Hygiene Department to ensure patient acceptance and compliance? Email

Interested in having Angie speak to your study group or at your next seminar? Contact her here.

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