In general, the financial obligation of the patient to the doctor for services rendered cannot be waived. This includes deductibles, and/or co-payments.
In addition, the fee charged for a service provided to an insured patient must be the same fee charged for the same service provided to non-insured patients in similar circumstances.
It’s unlawful in NJ to charge a higher fee to patients with Dental Benefits/insurance than to patients without insurance for the same procedure, and I believe unethical to say the least. Let’s talk about some common misperceptions regarding fees that may unknowingly get some offices in trouble.
Let’s say a cash discount is being offered for a particular procedure….maybe you are advertising a special this week on the web or in your direct mailing marketing pack….that discount must be offered to ALL patients; insured, uninsured, in or out of network…..it must be offered to all.
Mother’s Day is almost here. Mom has dental benefits and so in honor of Mother’s Day, you decided not to charge your mom the co-pay for her cleaning appointment….aren’t you generous (wink wink). You MUST disclose that “copay forgiveness” both on the claim form and in the patient ledger. Failure to do so may be considered “misrepresentation”. If you are in-network, it may also be a violation of your PPO contract.
If you provide a DISCOUNT for any reason, the fee listed on the claim form for the service provided should accurately reflect the fee charged to the patient. This means you should consider any cash discounts and/or patient courtesies and report them on the ADA claim form.
If the fee reported on the claim form is the full practice fee, but you discounted the patient’s portion, you are being dishonest (misrepresentation) AND, if the insurance carrier issues benefits based on the reported fee they will have overpaid. This is sometimes discovered in audits and if it is determined the insurance carrier overpaid then you will be obligated to issue a refund to the payer.
I know I harp on this quite often, so my apologies….but it is only because I know there are a lot of offices that are unaware of this. You don’t have to take my word for it….a portion of the State Board Regulation NJAC 13:30-8.1(c) states:
“A licensee who renders dental services or procedures to a patient enrolled in any dental plan with co-payment features and who intends to waive any part of the co-payment or all of the co-payment by the patient shall, when submitting any claim or bill to a third party payor, conspicuously disclose on the face of the claim or bill in a legible manner, or in the electronic claim submission, that the co-payment or a portion of co-payment, shall not be billed to, or collected from, the patient.”
I would also direct your attention to NJAC 13:30-6.62(n)(4) which states in part…
“Services advertised as complimentary, free of charge or for a discounted fee shall be offered equally to all patients identified as eligible in the advertisement (for example “new patients”), regardless of the patient’s third party coverage.”
It’s very nice to be able to offer discounts to our patients, but if you are considering providing this, make sure you report and disclose the offers you provide.
REPORT WHAT YOU DO!
DO WHAT YOU REPORT!
This includes fees.