ANSWER: Many states have passed laws that allow you to charge your full fee after the patient’s maximum is reached. Once the maximum kicks in it is considered non-covered and so legally you could do this. If you’re not sure if your state is one of these visit this page over at Unlock the PPO. You can bookmark it and check back since they keep it updated.
I have no problem with charging the patient your full fee as long as the patient is told about it ahead of time. The difficult part comes when a patient objects to the higher fee perhaps because they’ve already seen the lower fee on a proposed treatment plan or the insurance company’s explanation of benefits. Once the patient reaches their maximum they should have been informed of the change in fees. This is not an easy conversation to have and I would be sure to focus on the importance of moving forward with treatment. I would not focus on the fact that your state allows you to charge higher – the patient will not see this as a valid argument.
On a related note, the percentage of patients that actually have much work done after the maximum is not as high as you may think. The National Association of Dental Plan has stated that only 3% of covered patients use their yearly maximum. I definitely believe that you should encourage the patient to have the work done at their pace, not according to the insurance company’s fee schedule. However it is a fact of the dental practice that patients will want to maximize their benefits.
Teresa Duncan, MS, FADIA, FAADOM is an international speaker who addresses topics such as Insurance Coding, Office Manager Training and Revenue Growth. Her company Odyssey Management, Inc. provides virtual, customized training in these areas. She can be reached at [email protected].
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Alternating D1110 and D4910