Thursday Troubleshooter: Can this dental office upcharge on a PPO fee for Invisalign?

This orthodontist is frustrated and needs to watch the PPO fees

Jun 5th, 2014
Invisalgn Ppo

QUESTION: The orthodontist I work for hates the fact that we can only take the PPO fee for Invisalign cases and clear brackets because of the higher lab fee. He says his colleagues “upcharge” patients a cosmetic fee because of this. Are we allowed to do this? I thought we had to stick with the contracted fee we agreed to in our contract. I’m not sure what to do!

ANSWER FROM CINDI THOMAS,Forensic Consulting Services:
I do believe that some insurance plans allow more “esthetic” orthodontic options, and it may be possible to list the premium by using the code D8999. This approach may allow you to charge the patient the difference, according to Dr. Charles Blair — “Tips on Filing Invisalign Insurance Claims.” Contact the patients carrier to see if this is allowed.

Some insurance companies do cover Invisalign. Something else to consider is the possibility of negotiating a higher fee with the insurance carriers you participate with.

ANSWER FROM LYNNE LEGGETT, BS, FAADOM, Victory Dental Management:
Whenever someone mentions a PPO (preferred provider organization), you need to determine if your practice is in or out of network. If you are an in-network provider, then you’re aware of the allowable charge and the amount that you’ll need to write off. If you’re uncertain, obtain the eligibility of the patient and you will know what’s covered. Regarding the cosmetic fee charged, it’s allowable to add this to the claim. It’s been my experience that insurance companies will advise offices to include all fees, covered and uncovered, when submitting claims to accurately reflect the costs of doing business. However, if this benefit is not covered by the in-network PPO, you will be asked to write this off, and you will not be able to bill the patient for that fee.

I can understand your frustration with having a higher lab fee and wanting to pass on these costs to patients. If this burden of the higher lab fees continues to negatively impact the practice, you may need to reevaluate which PPOs you contract with as in network. Your choice will depend on the unique situation of your practice.

ANSWER FROM BRIDGET FAY, Odyssey Management, Inc.:
This is one of those frustrating situations for doctors and staff when they decide to become in network. If the doctor asks for your input, or if the subject comes up, the answer is that the office is required to abide by the contract fee. But, there might be some stipulations with certain contracts that make an allowance for cosmetic upgrades. You’ll have to give them a call, or pull out the contracts and do some light reading to find the details. If an insurance company finds out you’re not abiding by the contract fee, they have the right to drop the doctor from the plan, which might mean a significant reduction in patients referred to the office from the insurance company.

If you’re worried about your position in the office, this is a conversation you’ll have to have with yourself. First and foremost, do your due diligence by tactfully sharing your knowledge if the doctor asks for your input. From there it all depends on your situation and what you are comfortable with.

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