Question

Q: How do I know what to charge a patient when the patient has 2 PPO discount plans and I am
contracted with both plans?

A: Always charge the patient and her insurance company the full fee (the actual fee charged for the service
reflecting any discounts given) on the claim form. Never submit a PPO fee on a claim form. Also, record
the full fee on the ledger card. When the practice is contracted with 2 or more PPO plans, the patient’s
responsibility amount is the lowest contracted fee for each procedure performed.

Q: Can a provider be in-network at only one location?

A: Some PPO contracts allow a provider to be a contracted provider at only one location. However, this can vary by payer and/or contract.

Q: What is the difference between a DMO and PPO? How is the practice reimbursed under a
DMO?

A: A Dental Maintenance Organization (DMO) pays the provider a set monthly fee (capitation) for each assigned patient. A DMO plan has a set copayment for each procedure performed rather than a percentage of a contracted fee. Also, a DMO patient must receive dental care from an assigned participating provider. That participating provider agrees to accept the contracted fee for each procedure provided as payment in full, only charging the patient the required copayment, if applicable. On the other hand, a PPO has a contracted fee schedule with the provider, and the PPO patient is responsible for any copay and deductible.

Q: How do I negotiate fees with my PPO?

A: A doctor may negotiate fees directly with a PPO by contacting the provider relations department or a provider may hire a third-party to perform their fee negotiation. Please note that not all insurance companies will allow fee negotiation using a third-party. Rather than ask the PPO to increase all of your fees at the same time, you may have a better chance of success by choosing the top 10 to 20 revenue procedures performed in your practice. Then, negotiate a fee increase for just those procedures. See page 247-250 for more information on PPO fee negotiation.

Q: When a locum tenens doctor fills in for a doctor, who should be listed as the treating doctor when the locum tenens is not a contracted provider for the same dental plans as the owner doctor?

A: The name and NPI number of the doctor who actually performed the treatment must be reported on the
claim form. Most dental payers consider it a violation for a locum tenens doctor to not report himself as the
treating provider. However, some dental payers will grant temporary in-network status to a locum tenens
doctor. Others allow the owner’s name/Type 1 NPI on the claim with a narrative, “Procedures performed by
Dr. John Smith, NPI 1, locum tenens.” It is advisable to contact each PPO and a healthcare attorney.

Q: Treating doctor vs. billing entity – how are in-network fees determined?

A: The treating provider always has a Type 1 NPI number. The treating doctor’s Type 1 NPI number, license number, and provider status are reported in Boxes 53 through 58 of the 2019 ADA Dental Claim Form. The inor out-of-network status of the treating provider generally determines the reimbursement. If the treatment provider is out-of-network, then the patient may receive out-of-network benefits, if available and the payment could be made directly to the patient, not the billing entity.

A tax ID number is assigned to the billing entity and, depending upon the type of business formation it is (i.e., corporation, LLC, etc.), the billing entity may have a Type 2 NPI number. This information is reported in Boxes 48 through 52a of the 2019 ADA Dental Claim Form. Reimbursement from the payer is always made to the billing entity (not the provider) and the billing entity does not generally determine the in- or out-of-network status of the treating doctor.

Q: How is my required PPO write-off affected if the payer remaps a code, paying an alternate benefit?

A: Review your contract and Processing Policy Manual to determine your contractual obligations. Often you may be required to honor your contractual fee schedule for the remapped procedure. Sometimes, when an alternate benefit is provided for a non-covered procedure, your contract may allow for the alternate benefit to be considered an optional service. Contact the payer to determine if the alternate benefit will be allowed as an optional service, thus allowing you to balance bill the patient. Also see “Optional Services” on page 241-245.

Q: What fee should be reported on the claim form, the full practice fee or the PPO fee?

A: Always submit your full fee charged for the service on the claim form. Submitting your full fee on the claim allows for the following:

  • Proper calculation of patient benefits for COB by the secondary payer.
  • Payers review submitted fees to help determine fee schedule increases. Not submitting the full fee may result in missing out on this increase.
  • The practice can track write-offs for each PPO plan.
  • The practice will receive the benefit of any PPO fee increases.

Q. Our state recently passed a fee capping for non-covered services law. Why is the payer advising
us to take a write-off when the dental plan did not pay any benefit?

A: A PPO may control your fee for non-covered services in some cases. If your state has a fee capping (noncovered benefit) law, this law applies only to fully insured plans sold in your state. If a state has a fee capping law that applies to fully insured plans, the fee may still be controlled depending on if, and how the state law defines a covered service (which is state specific). If your state has a fee capping law (non-covered benefit legislation), but defines a covered service as “a service in which benefit would be available,” but a limitation of the plan document was applied, resulting in no payment or payment of an alternate benefit, then the PPO can control your fee. For example, a waiting period limitation applies to the claim, resulting in no payment.

For example, a patient receives 3 prophylaxis treatments in 1 benefit year, but the plan only pays for 2. The
frequency limitation is applied to the third prophylaxis since it is a covered service, thus the patient will be
responsible for the contracted fee only, not the full practice fee.

The plan may be a self-funded plan. Self-funded plans follow federal (ERISA) law, not state law. There is no federal law in place to prevent a self-funded or federal plan from controlling the practice’s fee. Self-funded plans are typically associated with large corporations such as Wal-Mart, Bank of America, etc. A plan may be self-funded if the verbiage on the patient identification card states “administration services only,” “ASO,” “plan administered by,” etc. A self-funded plan is one in which the employer is 100% financially at risk for all claims paid and the insurance company (third party administrator) is paid an administrative fee as either a set fee per claim or a percentage per claim to administer the employer’s plan document. A fully insured plan (under state law) is one in which an individual or a small employer purchases a dental plan from the payer and pays a monthly premium directly to the payer. The payer is 100% financially at risk for all claims paid regardless of the amount of premium received, and the payer is subject to the state’s law and the Insurance Commissioner.

Q: Our state passed a law preventing fee capping by a PPO. A patient purchased an individual PPO policy to receive the benefit of a lower fee during a waiting period. Our practice is contracted with this PPO. He plans to terminate coverage once treatment has been performed. Can we charge our full practice fee for his treatment not covered due to his waiting period?

A: Probably not. The patient will most likely receive the benefit of the contracted fee, even though no payment will be issued due to the waiting period, per the established criteria of the dental plan. The plan is dependent upon state law (if the plan is a fully insured plan).

In some cases, the terms established by the PPO can control your fee for non-covered services. If your state has passed a fee capping law, this law only applies to fully insured plans sold in your state. If a state has a fee capping law, the fee may still be controlled depending on how the state defines a covered service. The definition of a covered service is state specific. This means if your state passed a fee capping law, but defines a covered service as a service in which benefit would be available but a limitation of the plan was applied resulting in no payment or payment of an alternate benefit, then the PPO can control your fee. For example, a waiting period limitation could apply to the claim and result in no payment.

Q: How many patients actually max out their typical $1,500 annual benefit?

A: The answer is surprising! According to the National Association of Dental Plans, only 2.8% of people
participating with a PPO dental plan reach or exceed their plans annual maximum. Many people also have
Flexible Spending Accounts, which help pay for dental and medical care with pre-tax dollars.

If less than 3% of patients reach their plan year maximum, PPO plans that restrict fees for covered services have a far greater impact on doctors than fee capping restrictions for non-covered procedures after annual maximums are reached.

Q: Is it legal for a PPO provider to charge an upgraded lab or materials fee in addition to the
crown fee?

A: Any associated laboratory fees and materials are considered inclusive to the global fee for a crown. Reporting an additional fee may be considered unbundling. PPO providers should review each PPO contract and Processing Policy Manual regarding laboratory fees and materials.

One example, from Delta Dental, Dentist Handbook, National Processing Policies, January 2020 states the
following:

“Tooth preparation, temporary restorations, laboratory fees and material, cement bases,
impressions, occlusal adjustment, gingivectomies (on the same date of service) and local anesthesia
are considered to be included in the fee for a crown restoration. Separate fees for these procedures
by the same dentist/dental office are not billable to the patient on the same date of service. Fees
for buildups not required for retention are not billable to the patient.”

Optional services may apply in some cases. This allows the practice to charge the patient a higher lab fee for the upgraded service. See “PPO” on pages 241-245 for more information on optional services.

Note: This is a legal question and we advise that you contact a healthcare attorney who is knowledgeable
about the federal and state laws regarding this billing practice.