Question

Q: Can I have more than one fee for a given procedure?

A: Yes, as long as you consistently charge the same fee for each category of procedure. However, payers benefit only 1 fee for each procedure code. Having more than 1 fee will not affect what the payer reimburses. For example, you could have 2 fees to routinely report fluoride varnish, a lower fee to report fluoride varnish for adult patients (since it is typically out-of-pocket) and a higher fee for pediatric patients. The practice may also have 2 fees for a comprehensive periodontal evaluation (D0180). One fee is for a new patient evaluation, and another lower fee for a periodontal evaluation. The practice management software may differentiate between the 2 fee levels by adding a letter at the end of all CDT codes, for example D0180A and D0180B. However, the A or B is removed by the software when the claim is filed.

Q: Is it legal for our practice to charge a finance charge if our signed financial agreement does not state as such (for example “Finance charge may apply to your account for any unpaid balance not paid within 90 days of treatment.”)?

A: Many PPO contracts (or Processing Policy Manual) prohibit an in-network doctor from charging a finance charge. Additionally, many states require the patient be notified in writing, in advance, of any intent to assess a finance charge. This law varies by state. Contact your State Dental Board or State Dental Association for referral to the appropriate agency to determine the healthcare collection laws in your state.

Q: Upon review of some of our Medicare Advantage Plan EOBs, we noticed a 2% reduction in our reimbursement. We are not contracted with the payer, nor are we enrolled as a Medicare provider. The payer’s explanation is that the 2% reduction is a result of Obamacare, and that we are required to write it off. Is this reduction in benefit legal?

A: Yes, this 2% reduction is a result of the sequestration, The Budget Control Act of 2011, and applies to
Medicare fee-for-services plans. Former President Obama issued this sequestration order on March 1, 2013 for services received on or after April 1, 2013. Not all Medicare plans follow this order, but this particular Medicare Advantage Plan follows the order, thus reducing payment to the provider by 2%. This reduction applies regardless of the provider’s in- or out-of-network status or Medicare enrollment status. To avoid this reduction, you may collect payment in full from the patient at the time of service and assign benefits to the patient, as this order does not apply when the payment is made directly to the patient.

Q: Our practice is in-network with 1 payer and out-of-network with another. Recently our EOBs from the out-of-network payer have indicated the claim was processed as if we were an innetwork provider with their contracted fee schedule, resulting in a write-off. We contacted the out-of-network payer and were informed that our practice is obligated to honor the lower fee schedule even though we do not have a current contract with them. How could this happen?

A: The terms of a PPO contract may allow the sharing or leasing of a doctor’s participation with other networks, thus obligating the doctor to the lowest of the many fee schedules within that shared network. Refer to your PPO contracts for these details, as this is not uncommon. Contact the provider relations department to inquire about an opt out option.

Q: If our practice is out-of-network, are we allowed to increase or decrease our full practice fee
based on our knowledge of a certain plan’s contracted fee?

A: No. You cannot adjust fees in this case and should always charge the full practice fee. Be consistent in
reporting! For example, if you know that Mrs. Jones’ plan pays $30 for a prophy and Mr. Patterson’s plan pays $80 for a prophy, you cannot charge less for Mrs. Jones with the intent to lower her out-of-pocket expense.

Q: If our practice is out-of-network, can our fees be increased if a patient or procedure is difficult
and requires more time? Is it ever appropriate to decrease our regular fee?

A: Yes, but the fee submitted should be the fee you intend to accept as payment in full for the service you provide. For example, if a patient is more “challenging” and requires more time and effort to treat, you may increase your fee. Additionally, if a composite is simple and requires very little time (e.g., requires no anesthesia) you may decrease your fee. However, be cautious of routinely decreasing fees. If audited, you would not want to show a pattern of lower fees for non-insured patients and higher fees for insured patients. For example, the practice should not show a pattern of taking a panorex for all covered children at age 7, but not taking a panorex for 7 year old children without insurance coverage. You are required to treat all patients equally and with the same clinical protocols, regardless of finances or insurance coverage.

Q: We received a letter from a payer requesting that we accept a lower fee for a claim. We are an out-of-network provider. Are we required to accept this fee and what happens if we do?

A: No, you are not required to accept the negotiated fee that is offered. However, if you do, you are agreeing to accept this fee as payment in full and cannot balance bill the patient. This negotiated fee acceptance is for this claim only and will not affect network participation on future claims from this payer as long as the dentist continues to be an out-of-network provider.

Q: Can I have a different fee schedule for patients without insurance (dental benefits)?

A: No, the fee for patient’s without dental insurance should be considered the dentists full fee. This fee should be represented to all payers, regardless of any negotiated fee discount. You cannot have one fee for patients with benefits and a separate fee for patients without benefits.