Many employers provide their employee with dental treatment as a benefit of employment. The employer may provide all dental treatment at no cost with the exception of lab fees. However, what are the considerations when an employee has dental benefit coverage? Should the insurance be billed? How much should be billed? What happens if the benefit is maxed out? These are all questions that pertain to professional courtesy discounts.
Offering professional courtesy discounts dates back to Hippocrates. The practice served to build bonds between doctors, and to reduce the incentive for doctors to treat their own families. There are stipulations on the correct way to offer professional discounts when an employee has insurance. The keyword is disclosure.
As a contracted provider in a dental plan, under what circumstances can a dentist waive patient/employee responsibility for co-pays, deductibles and non-covered services?
Most dental plans are not designed to cover 100% of all costs. Patients are usually expected to share in the cost of the treatment. A typical plan might cover 80% of the cost and the patient would be responsible for 20%. A participating dentist may occasionally offer patients discounts in instances of professional courtesy or financial hardship; however, this must be disclosed to third party payers on the claim form. A dentist who regularly writes off or fails to collect the patient’s portion misrepresents to the dental carrier the fee actually charged. The American Dental Association policy on waiver of copayment states “ A dentist who accepts a third party payment under a copayment plan as payment in full without disclosing to the third party that the patient’s payment portion will not be collected, is engaged in overbilling.
The essence of this ethical impropriety is deception and misrepresentation; an overbilling dentist makes it appear to the third party that the charge to the patient for service rendered is higher than it actually is. “
If a dentist submits a claim for an approved fee for $100.00 but accepts the payment of $80.00 as payment in full, the dentist’s actual fee is only $80.00. Misrepresentation of the actual fee charge is known as overbilling. This may lead to termination of participation agreements and may be reported to the state licensing board. The correct way to report discounts on claim forms is to enter the fee the dentist intends to collect as payment in full in the total fee column of the claim form. This insures the discount is applied to both the plan portion and the patient portion. A comment should also be documented in the remarks section of the claim form indicating an employee discount has been offered, and the patient responsibility has been waived.
When the fee charged to the patient is lower than the dentist’s usual fee, and it is correctly entered on the claim as the actual fee charged, there is no effect on the dentist’s participation agreement. It is also essential to fully document the treatment in the patient chart.
Once the dental benefits have reached their maximum through the dental plan, the continuation of benefits may be outlined in the employee manual.
After [for example, three months] of service, [employer] offers dental treatment for eligible employees as a benefit of their employment. These dental services are available to the employees’ family members: [for example, your spouse, significant other, domestic partner, child, parent, legal guardian, brother, sister, grandparent, grandchild, any in-law, and any person with whom you reside] at [for example, no charge, a percent discount].
Dental treatment is available subject to the following: [list the yearly limitations, who is responsible for lab fees, appointment hours, dental insurance and types of services available under the plan]. Dental benefits are at-will and may be modified or cancelled at any time at [employer]’s discretion.
So, if you offer an employee with dental coverage a professional discount, what steps should you take?
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