3.12.10 Issue #418 Forward This Newsletter To A Colleague

Carol Tekavec
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When Should An Office Report the Full Fee?

Many offices have questions concerning when it is appropriate to report a dentist’s full fee for a service. This is typically because dentists nationwide are often involved in dental benefit plans where they may have accepted a “network fee schedule” mandating fees that are less than the dentist’s “normal” fee. Some dental plans request that a dentist working in their network always report the fee they have agreed to when filing a claim, not their normal fee. Making the situation even more confusing are plans that require a participating dentist to charge a patient a network specified fee, even for services for which the plan is not going to pay anything! (The Rhode Island Dental Association recently was successful in getting legislation passed in that state prohibiting this practice.) This would include fees reported for services provided after the patient’s maximum annual benefit has been reached.  So, here are the issues:

  1. When a dentist has contracted with a plan, should he/she report the plan “fee schedule” fee when filing a claim for a patient?
  2. Which fee should be filed if a dentist is a network provider for more than one plan?
  3. Which fee should be filed if a patient has more than one benefit plan?  
  4. Which fee should be filed when a patient is receiving services after their maximum benefit has been reached?
  5. How do dental plans come up with their fee schedules in the first place?

Let’s look at question #5 first.  Many plans refer to their fee schedules as “UCR” or “Usual, Customary and Reasonable.” However, these fee schedules are actually tables of fees derived from the fees reported by dentists and then broken down by percentages in a geographic area. They are not necessarily what the majority of dentists in an area are “usually, customarily or reasonably” charging. 

More simply put, all of the fees that are reported by dentists to benefit companies are entered into certain data bases. These data bases may be maintained internally by a specific carrier or a carrier may purchase the data from a central source, gleaned from carriers across the nation. When an employer purchases a plan, they look at this fee data base as it relates to the premium cost. Fees that are in a higher percentage spectrum require a higher premium.

Once the employer has decided on the premium cost they are willing to accept, the correlating fee becomes that plan’s UCR.  So, even if few dentists in a geographic area are actually charging a certain fee, that fee, the “negotiated fee,” can become the fee a dentist must accept when becoming a network provider for that employer’s plan. When the patient is required to cover a co-payment, such as 50% for crown and bridge procedures, that 50% is not derived from the dentist’s regular fee, it is taken from the negotiated fee, which is probably much lower. (Future articles will detail how to explain this complicated issue to your patients.) Therefore it is easy to see that since the data bases of reported fees are where plan fees are derived, dentists must report their regular fees in order to prevent lower and lower fees from being listed.

Now we know the answers to questions 1 through 4. A dentist should always file his/her regular, full fee when sending in a claim for a patient. The plan will pay what it will, the patient pays according to their policy, and then an adjustment can be made to the patient’s account to reflect the dentist’s network provider agreement. Again - dentists file their full fees and make adjustments later.

The ADA House of Delegates finally took a stand on fee reporting at the 2009 Annual Session in Honolulu.  Here is their Resolution 44H-2009:

  1. A full fee is the fee for a service that is set by the dentist, which reflects the costs of providing the procedure and the value of the dentist’s professional judgment.
  2. A contractual relationship does not change the dentist’s full fee.
  3. It is always appropriate to report the full fee for each service reported to a third-party payer.

Carol Tekavec CDA RDH is a speaker on dental records, insurance coding and billing, and patient communication for McKenzie Management.  Interested in having Carol speak to your dental society or study club?  Click here

 Interested in knowing more about how to improve your hygiene department? Email hygiene@mckenziemgmt.com.

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