Question

Q: Family members of team members receive a 50% discount for dental treatment. May we provide the patient (family member) with a bill reflecting the full amount, then apply the 50% family discount, allowing the patient to submit his own claim? Since any benefits available would be assigned directly to the patient, our practice would have no knowledge of the amount reimbursed.

A: No. This is considered overbilling and a material misrepresentation of the actual fee charged for the service. The claim form or detailed receipt provided to the patient should always reflect the discounted fee (actual fee charged to the patient), to ensure that insurance reimbursement is not greater than the actual fee charged. This is inappropriate and the patient and/or doctor could be held liable. If the provider knowingly participates in this billing practice, it may be considered insurance fraud by a court of law.

Q: A crown is prepped, delivered, and reimbursed by the payer. The crown fails shortly thereafter,
the tooth is extracted and the patient needs a bridge. The doctor wants to offer a treatment
credit to the patient for the failed crown. How should this be handled?

A: The fee submitted for the new bridge should reflect the discount (treatment credit) given to the patient.
The fee reported should be the fee the doctor intends to accept as payment in full for the new bridge. All
discounts must be deducted from the full practice fee, and the discounted fee (actual fee charged) reported
on the claim form. It would be improper to give a discount toward the patient’s copay and not submit the
actual fee the doctor intends to accept as payment in full for the service provided.

For example: The original crown fee was $1,000, and the patient paid $500. The doctor gives the patient a
credit of $500 towards the new bridge. The full bridge fee is $2,800, but the fee reported on the claim form
should be $2,300, not $2,800, since the patient received a discount of $500.

Q: Sealants were performed on a pediatric patient during a routine hygiene appointment. The parent refuses to pay the remaining portion, after the insurance has paid, stating the practice caused the need for the treatment. Clinical notes stated that sealants were needed prior to this recall visit and this was  discussed with the parent at the last recall visit. How should we handle this situation since the practice does not want to lose a family over the small amount due? Should we write off this balance and if so, are we required to notify the payer?

A: It is important to get a signed consent for treatment prior to performing treatment. However, if the parent
consistently refuses to pay, expecting the balance to be written off, this is a pattern and dismissal of the
patient is in order. If audited, it could be problematic if a large proportion of accounts reflect that write-offs
were routinely made. Avoid this situation by presenting a treatment plan and having the patient sign the
treatment plan and/or pay her portion prior to treatment.