Carol Tekavec, RDH
Dentists may elect to participate or not participate with insurance companies where patients` benefit payments are concerned. Accepting direct insurance payments on the patient`s behalf (assignment of benefits) should be considered carefully and monitored vigilantly.
A dentist may work with a state Delta plan as either a participating or nonparticipating provider. Participating providers are required to file their fees with the state Delta office and have these fees "approved."
They also must sign a contract agreeing to accept the fee arrangements that Delta has approved, along with any other required stipulations. If the dentist is participating with only the indemnity side of reimbursement, the patient can be billed for the difference between the Delta payment and the dentist`s approved filed fees. If the dentist is participating in a Delta Preferred Provider Organization (PPO) plan, the arrangement is different. The dentist must agree to accept Delta PPO payments, along with a limited copayment for certain procedures, as the total fee.
If the dentist has not signed a contract with Delta and is therefore not a Delta participant, he or she may submit any fee on patients` claim forms, but patients will receive reimbursement at a lower percentage than they would if the dentist was participating.
Assignment or nonassignment
Dentists usually look at accepting direct-insurance payments in one of two ways. If the dentist accepts the check, then he or she is assured that payment toward the patient`s account is made. If the dentist does not accept payment, the patient may elect to spend the insurance money on some other item. Assignment carries with it the implied responsibility of dealing with the insurance company. Patients expect the office to assist them in receiving benefits. Non-assignment places the responsibility of working with the carrier on the patient`s shoulders. To minimize problems with either method, the patient should be presented with a fee estimate prior to treatment. The fee estimate should stipulate that the total fee is due from the patient, regardless of what insurance eventually covers.
Recently, some carriers have begun to use yet a third payment mechanism. A dentist who is not a participant with a particular insurance plan agrees to accept assignment of benefits on behalf of a patient. When the check arrives, a statement is included in the endorsement area that reads something like this: "This check represents provider payment according to the terms of our Preferred Provider contracts or reasonable and customary charges. Negotiation of this check constitutes confirmation of your agreement to these charges."
In other words, if the office endorses and cashes the check, the dentist is agreeing that the payment will be accepted as payment in full from the insurance carrier, regardless of the fact that no participating-dentist contract has been entered into by the dentist! Patients in these cases often also receive an Explanation of Benefits that indicates that the dentist`s charges are above the carrier`s "usual and customary" charges, and that the patient need only pay the amount listed on the EOB. This further complicates matters, because the patient may wrongly assume that the dentist is somehow required to accept the fees offered by the insurance carrier.
The best way to guard against this practice is to carefully scrutinize any benefit checks your office receives for this type of endorsement language. If one arrives, void the check and mail it back to the insurer, explaining that your office will not accept the company`s fees as total payment. Patients also should be alerted about your response, so that the negative EOB they might be receiving will not come as a surprise. Future assignment of benefits from that particular carrier should be curtailed.
Carol Tekavec, RDH, is the author of two insurance-coding manuals, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or at www.steppingstonetosuccess.com.