As dental students, we tend to focus on gaining as much clinical experience and knowledge as we possibly can during our dental school years. We try our best to avoid the confusing world of insurance, not thinking about the eventual contracts we will likely sign with dental insurance companies, or “third party payers”. Within these written agreements are a number of possible stipulations and common practices that will affect the way we run our practice and treat our patients.
For example, what if I told you that as an out-of-network, or non-participating provider, a dental insurance company could refuse to forward reimbursement to you, as this would be considered a “perk” of being an in-network contracted dentist? The patient’s signed request to assign benefits to you would be ignored. Or, what if I told you that due to a “least expensive alternative treatment” clause, you could only be reimbursed for a removable partial denture, the less expensive treatment option, even though you and the patient agreed on a fixed partial denture? The following is a list of common dental insurance practices for which every dental student and new dentist should be aware:
Downcoding and changes in procedure codes
Downcoding is when a dental procedure code is reimbursed at a lower rate than the actual procedure reported. For example, a DO composite will be reimbursed as a DO amalgam. Third party payers also sometimes reimburse for a different dental procedure code than what was originally submitted. They are not allowed to change the code, per se, but can acknowledge the submitted code and then reimburse for something different.
Bundling is the combining of more than one dental procedure code, effectively denying payment for one or more dental procedures. For example, some insurance plans will combine panoramic and bitewing radiographs and provide reimbursement for a full mouth series, which many plans only pay for once every 5 years, even though a true full mouth series was not taken.
Some insurance contracts involve the practice of capping fees on services the insurance plan does not cover. Under such plans, a dentist is obligated to charge no more than the plan’s set fees on non-covered services. This often means the dentist could lose money on some non-covered services, even if the patient and dentist agree that the non-covered service is in the patient’s best interest. In this case, the role of the dentist as the clinical professional is compromised by a third party for financial reasons.
Legislation has been passed in 35 states preventing insurance companies from capping what a dentist can charge for a service that the insurance company does not even cover. However, some plans have moved certain non-covered services into the covered category at an extremely low reimbursement rate, effectively capping the services. Some states now require covered services to be minimally reimbursed at 50 percent in order to be considered a covered service.
What Can I Do?
Before considering signing any Dental Provider Contract, use the ADA’s Contract Analysis Service, which is free of charge for ADA members through their state dental society. (Remember, all predoctoral ASDA members are also members of the ADA. If you’re not an ASDA member, click here to join now.) Additionally, check out the ADA’s Center for Professional Success for FAQs and resources to succeed as dental professionals and small business owners.
-Tony Besse, Ohio State ’16, chair, Council on Professional Issues