Be clear when discussing dental benefits with patients

By Ann Milar, CDA dental benefits analyst

“Do you accept my insurance?” this is a question that thousands of dental offices receive from prospective patients multiple times per day throughout the country. How your dental team responds to that question can set the tone in terms of patient expectations and determine the future of the doctor- patient relationship.

In recent months, the question of how dental practices should be answering that question has become a discussion point for CDA members. Why?

With as many as seven out of 10 patients with dental benefit coverage being enrolled in dental preferred provider organizations (PPOs), patients are encouraged to seek treatment from an in-network provider for their dental benefit plan. When patients do seek treatment from in-network providers, the patient’s out-of-pocket costs are generally lower since participating PPO providers usually agree to a reduced fee schedule with contracted plans. Patients are usually responsible for their deductible, applicable co-payments and any non-covered services.

There may be some dental practices that unintentionally provide incorrect information to their prospective patients when the patient asks “Do you accept my insurance?”, thus misleading the patient. This is a direct violation of the CDA Code of Ethics.

The CDA Code of Ethics addresses this type of behavior in Sections 6A: False and Misleading Advertising and Solicitations, and Section 7: Billing Practices. The Code states that “a dentist shall avoid any representation that causes patients to believe the dentist is a provider for the patient’s third party payer if, in fact, the dentist is not.” Additionally, “it is unethical for a dentist to mislead a patient or misrepresent in any material respect, either directly or indirectly, the dentist’s identity, training, competence, services or fees. Likewise, it is unethical for a dentist to advertise or solicit patients in any form of communication in a manner that is false or misleading in any material respect.”

Dentists are entrusted with the responsibility to do no harm, yet this type of false and misleading communication certainly poses potential harm to the patient. Dentists should understand that the foundation of a successful doctor-patient relationship is trust and honesty. If a dentist is misleading a prospective patient by providing false or partial information about what costs the patient may be responsible for, it brings into question whose interests are coming first, the patient or the dentist?

Here are some suggestions on how a dental practice should address the patient’s question about accepting their insurance: First, the staff should ask the patient which dental plan they are enrolled in. If the dentist is a contracted provider for the patient’s plan then the staff can let the patient know that, yes, they are a contracted provider for the patient’s plan. If the dentist is not a contracted provider for the patient’s plan, the team member should let the patient know that they are not a contracted provider for the patient’s plan, but that the office is willing to bill the patient’s dental plan as a courtesy.

Failing to accurately state whether the dentist is a contracted provider for a dental plan will lead to patient issues with the practice, guaranteed. While patients are becoming increasingly more educated about their health coverage and are monitoring their out-of-pocket costs for treatment, many do not know that the question they should be posing to a dental practice is “Are you a contracted provider for my dental plan?”

As a result of not asking the appropriate question and seeking treatment from non-contracted dentist, the patient may be faced with an unpleasant surprise when they receive a statement showing an unexpected balance due. Understandably, patients are frustrated and caught off guard that their financial responsibility may be much higher than anticipated. This can lead to patient dissatisfaction, possibly resulting in the patient moving onto another dental practice, albeit more knowledgeable about their dental plan network.

Updated: 08/26/14