Why Waiving Dental Co-payments is a “No, No”

Although dental coverage today is different from true “insurance”, in that the plan sponsors pay for all the claims members use, plus an administration fee to the Insurer, dental coverage is viewed consistently as one of the most important and highly desirable aspects of an employee benefit plan.

Recently, dentistry has been under scrutiny. Insurers are much more vigilant about fraud, abuse, and insurance scams. One area that has come under increased visibility is the practice of dentists forgiving patients for the patient’s portion of coinsurance; something for which the Royal College for Dental Surgeons has warned its members about and that falls under professional misconduct as insurance fraud and something that has silently existed for years.

Dentistry is guided by complicated codes that consumers have no way of deciphering and are often unaware of what services are actually performed.  Scaling and polishing are different procedures, but because they are managed in the same appointment, there is ambiguity.  Additionally, what is a unit of time?  Most would not know that one unit of time represents 15 mins of services and of course, no one knows which codes denote what units of time.

Added to the mystique, is the practice of a “cash price” and “insurance price”, which at first blush seems underhanded, while on the surface is quite legal; so long as the dentist submits the reduced or “courtesy” price to the Insurer and provides a full accounting of all work that was performed for that price.

Where things get dicey for the dentist and potentially the patient is when there is a negotiated discount of some kind, but the discount is not transmitted on the bill to the Insurer.  The invoice to the Insurer must reflect the cost of the services (if there is a discount of 20% to the charges), the dentist office cannot transmit the full (un-adjusted) charge to the Insurer. By law, a claim made to an Insurance company must be an accurate description of services rendered and fees charged.

Dentists who are in essence reducing their fees, when they do not intend to collect patient copays, are misrepresenting work charged to the insurance company.  This is grounds for professional misconduct, which can result in a dentist losing their license and incurring fines in excess of $10,000.

How is dental fraud classified?

Dental fraud is any act of intentional deception or misrepresentation of treatment made for the purpose of gaining unauthorized benefits. This can include billing for services not rendered, misrepresenting dates of service, overcharging or upcoding routine services — and of course, as outlined here, waiving deductibles and/or co-payments.

Dentists must maintain accurate and complete records to their governing body that they made successive reasonable attempts to collect outstanding copayments from their patients.

Do Dentists have options to help their patients?

Dentists can choose to accept lower fees for the work performed on their patients by applying reimbursement from a previous fee guide that is being used by a Third-Party Adjudicator (Insurer). Most benefit plans utilize the Current provincial fee guides (which increases annually). An approach a dentist might consider using is to apply a “lagged fee guide” i.e. Current, minus 2 years.  In this approach, the benefit plan would reimburse the patient based on the Current fee guide, while the patient is charged copay based on the 2 year lagged fee guide.

It’s important to note, however, that from a Plan Sponsor’s perspective, an 80% reimbursement plan remains more cost-effective for the employer because 80% of a claim is less than paying the 2-year lagged fee guide reimbursement for dental services.  So, employing this strategy to provide employees with the legal authority to negotiate fees with their Dentist would be a poor cost management strategy.

2020-02-02T15:50:19+00:00