November 2018 Volume LIII Number 6

 
 
 
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Behind the Code: Should I Report My Full Fee Or The PPO Fee On Claims?

November 2012 Volume XLVIII Number 6

 Question

 

Can you please clarify whether dentists can charge different fees for their fee-for-service patients versus their PPO patients?

I thought that we should bill the same fee for all of our patients (even if we are a PPO provider), then take any contractually required write-off after we receive payment from the patients dental plan. I relayed this information to my current employer and co-worker. They charge out separate fee schedules to avoid the hassle of the write-offs. Ive only worked in full fee-for-service practices in the past, so I am not familiar with billing PPO plans. I want to make sure that I am billing correctly.

 

Answer

While it may be easier to simply bill the PPO fee on claims, doing so is not a wise business management decision. The ADA encourages dentists to bill their full fees on all dental claims and take contracted writeoffs after the claims have been paid. According to Chris Smiley, D.D.S., former chair

of the ADA Council on Dental Benefits Programs, "Your full fee is what you would charge for a service independent of any contractual agreement. It is not the maximum allowable benefit of the dental plan, unless you adopted the plans discounted fee schedule as your usual fees. The full fee you report on a claim may also differ from your office fee schedule, as it is always appropriate, on an individual basis, to modify this fee based on the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances you may encounter during the course of care.

"If you are a participating provider, you have agreed to accept payment based on the plan maximum. However, it is understood that you have a ‘full fee’ that differs from the contracted discounted fee, and it is that ‘full fee’ that you should report on a claim form.

Plan administrators need this information to determine market trends for fees. If you submit the contractually discounted fee, you skew the maximum allowable fees that arcalculated by the carrier based on the claims data they receive from dental offices."

Five reasons for billing your full fee:

Sometimes a PPO plan raises its allowable fees but fails to notify contracted providers prior to doing so. Billing your full fee ensures that you will receive the highest PPO fee available. 

Most large dental insurance carriers collect the fees you submit on claims and analyze that information to determine future fee increases for your practice. If you always bill your contracted fee, you may never qualify for a fee increase.

The fees submitted on dental claims are compiled into a national database that is used to develop the average fees charged in each ZIP code area. Dentists who bill their PPO fees on claims negatively affect the aggregate fee data, which hurts all dentists in that area.

Some secondary payers are required (by contract law or state law) to coordinate up to their allowable fee if it is higher than the primary dental plans allowable fee. However, the secondary plan will never coordinate up to a higher fee than you charge on the claim form. If you charge your full fees, you may find that some secondary plans pay more than the primary dental plans contracted fee and you can reverse all or part of the writeoff required by the primary plan.

From a management perspective, it is essential to be able to perform an "apples to apples" comparison of PPO networks to determine which ones are most profitable.

This involves not only comparing fees but also monitoring how a carriers processing policies trigger write-offs. Reporting full fees on claims and analyzing the total write-offs compared to the total charges for each PPO network allows a dentist to understand the true costs and benefits of participating in each network. PPO plans now represent approximately 74 percent of the dental benefits market and continue to grow. Increasingly, dentists will need to evaluate different PPO networks.

For further information, please contact AAPD Dental Benefits Manager Mary Essling at (312) 337-2169 or messling@aapd.org.