Conscientious Billing Practices: Ethical Decision Making for Patient Billing and Dental Benefit Company Relations
Before you set out to treat a patient, always pretend that you are the patient and then treat your patient how you would want to be treated.
One of the main content areas that was lacking in my dental training included business management. Upon graduation, we were set loose on to the world to become small business owners, CEO’s of our own company. As we are thrown into practice, we become human resource managers, chief financial officers, inventory management control specialists, and corporate relations liaisons, all in addition to focusing on our dentistry. No one gave us a course on how to manage billing or dental benefit companies. We created a fee schedule from various practice management gurus, respected journals, thought leader articles and word-of-mouth discussions with colleagues. We filled out claim forms (sometimes by ourselves, occasionally by a team member) and prayed for accuracy and timely payment.
The world is a little different now. Currently, with the Health Insurance Portability and Accountability Act (HIPAA) and Fair Credit Billing Act, the way we charge for and collect professional services has changed. We are not allowed to harass patients, through the office or collection agencies, if they do not pay their bills. I remember, many years ago asking a patient, in complete frustration, “Why do you have money to pay for your (Chicago) Black Hawks tickets, but do not have anything to pay me?” It was not a good tactic then and certainly not now. We have to protect the sanctity of our patient’s privacy.
As mentioned, one of the first tasks in starting your practice is to set a fee schedule that you feel is a fair return for your professional skills and knowledge. Once a fee schedule is determined, it is necessary to stick with those fees. Charging differently for the same procedure is not a good practice protocol. It is also unlawful to charge dental benefit patients differently than fee for service patients. It is also unlawful to charge for procedures you have not provided. In addition, it is unlawful to overcharge for procedures provided to maximize either your or the patient’s return from the benefit company.
Billing the patients should be fairly basic. The first rule of thumb: be honest with your patients and only charge them for procedures that have been performed. Have financial discussions prior to treatment. These discussions should be held by your business manager, front desk manager, or yourself. The entire treatment plan should be described, with alternatives of care, demonstrating fee schedules of each procedure. The more conversations you have with your patient regarding their financial obligations, the happier the relationship will be. Patients leave dental practices for many reasons such as moving, changing dental plans, and owing money. If you are able to avoid trying to track the patient down after he or she leaves your practice, then you will save yourself a huge headache.
If a patient has a dental benefit, offer to submit the treatment plan as a pretreatment estimate to their company. This will allow you to know the “estimation of benefits,” the amount the benefit company plans to pay. This amount may vary, due to other dentistry being performed outside of your office. It will also indicate the percentage breakdown for each procedure. You will be able to explain these benefits to the patients. It is to be noted that treatment planning is between the dental professional and our patient. Although dental benefit companies feel they have the “right” to dictate treatment, they are only offering suggested amounts of reimbursements. This should never dictate the treatment you feel is best for your patient. Regardless of your office policy to accept or reject dental benefit, it would be prudent to have these pretreatment authorizations in place. It will also indicate if a procedure is covered under the plan and will lead to an easier discussion of financial obligations with your patient.
Early on in my practice, I had a new family join us. The wife was a stay-at-home mother with three children, one new born. The reason they were changing dentists was inconceivable. Their former dentist had all the dental benefit information, knew the father’s (head of household) information, as it was the same for the other children, and filed a claim for a preventive visit for the young child who had never visited his practice. This is major fraud and not a wise choice. Only request payment for procedures you have personally completed and list the procedures thoroughly and accurately.
I also had an opportunity to work for a major dental company in the fraud division. I was assigned a group of dentists who were “on hold” from this carrier because they repeatedly filed similar claims for large groups of patients. For example, some dentists only charged for the initial oral examination for an entire group of residents at a nursing care facility, some of whom had no teeth, never had prosthesis, or were physically unable to wear prosthesis. Another group of dentists charged out single surface amalgams on every posterior tooth, from molars to premolars, regardless of the age of tooth eruption. For the most part, none of these procedures were necessary; some were not even performed. Again, if you think that you are submitting claims unheeded, then beware. With electronic claims payment, the accounting is simple. There is always someone evaluating the number of claims and procedures processed. If you perform too many of one procedure, you may receive a letter from the company, requesting files and treatment plans.
Regarding dental fees, it is prudent to reassess them on a yearly basis. Try not to change fees midyear. If you have a treatment plan in place with a patient, it is not wise to alter the contracted amount. One option would be to set a time limit with the patient. “This treatment plan is in effect for _______.” Oral conditions do change. Treatment may not be as expected. Patients need to be aware of this from the onset of care. They should sign the treatment plan and the financial arrangement to agree that there may be unforeseen changes. It does not make for good business or client relations to radically increase fees in the middle of a treatment, unless there is an unforeseen gap in the treatment. Then, you may reassess, reanalyze the oral conditions, and create a new treatment plan. Do remember that the best patients will come from your best patients. It is wise to make patients happy by having open and honest communication.
To accept or not to accept a dental benefit is the question you must answer when you begin your practice life. If you are in an associateship, you will be under the restrictions of your employer. They may or may not take dental benefit, and you are obligated to work with their restraints. As a solo practitioner, or as the partner in a group practice, you need to decide if you want to enter into the “insurance game” or go it alone.