Thursday Troubleshooter: Can dental practice forgo insurance payment if patient agrees to treatment amount?

Oct. 24, 2019
This dental office manager wants to know if it's legal to skip insurance if the patient agrees to pay the treatment charge. Find out what she's advised.
Problems! Who doesn't have them? If you have a problem or concern in your dental office position, you might be too close to the situation to solve it yourself. Share your concerns with Team Troubleshooter. The experts will examine your issues and provide guidance. Send your questions to [email protected].QUESTION: Our dental office just hired a new dentist who works a lot with TMJ patients (assessments, records, and appliances). This takes quite a bit of chair time. We are a participating dental practice with many insurance companies. Can we forgo all insurance for TMJ treatment if the patient is willing to pay out of pocket? For example, if we charge $400 for an appliance (we use an appliance code) and the insurance company allows us to charge only $200 for that code, it is just not worth our time. Is it legal to forgo the insurance company’s payment if the patient agrees to the charge? Any advice you can share would be helpful. 

ANSWER FROM PATTI DiGANGI, founder of DentalCodeology:
With a new dentist and different procedures, coding dilemmas will arise. The response to your question is less about the time and treatment and more about the contracts that have been signed by the practice. Contracts are serious documents with legal ramifications.

As I wrote in a previous Troubleshooter, many times contracts are signed by one person, but the administration of the contract is performed by someone else. Further, the administering person never sees the contract signed. Finally, whether the signer or administrator understands all the legalese in the contract is often questionable. Some offices sign on to a plan’s network only to discover that the plan has certain policies and procedures that the dentist disagrees with.

Analyzing and reviewing a contract prior to signing it can save considerable time and frustration. In my experience, contracts generally favor those who are bringing it. So, do contracts favor what the carrier wants? Absolutely, this is their business.

Get copies of each plan’s contract handbook. These will typically explain the benefits, limitations, and more. Make sure you know and are following the rules of the plan. Unfortunately, fraud by accident or ignorance of the policy signed is still fraud. If you are an in-network provider, you are obligated to follow the plan’s processing guidelines. If it states that no fees can be charged to the patient, then you cannot charge the patient. If the fee allowed does not seem adequate or does not cover the cost of doing business, other decisions need to be made.

One of those decisions includes a deep consideration while deciding on plan participation when those contracts come due for renewal. A good question to ask is, will contracting a plan damage my practice more than if I had never contracted? When starting a practice, these decisions are important. 


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Don't be shy! If YOU have a tough issue in your dental office that you would like addressed, send it to [email protected] for the experts to answer. Remember, you'll be helping others who share the same issue. Responses will come from various dental consultants, as well as other experts in the areas of human resources, coding, front office management, and more. These folks will assist dental professionals with their various issues on DentistryIQ because they're very familiar with the tough challenges day-to-day practice can bring. All inquiries will be answered anonymously each Thursday here on DIQ.