For benefits with age limitations like fluoride and orthodontics. Are we required to take the write off for in network plans or can the patient be billed full fees? My practice is located in Florida.
Great question! If your state has a fee capping law (non-covered benefit legislation) but defines a covered service as “a service in which benefit would be available,” but a limitation of the plan was applied resulting in no payment or payment of an alternative benefit, then the PPO can control your fee because the service is considered a covered service, it was just not reimbursed. Check out DCS' Fee capping article for more info: www.dentalclaimsupport.com/blog/fee-capping-dental-insurance
Hi! Thanks for your question! To figure out what the patient's responsibility is, you should always subtract the remaining deductible amount from the allowed amount (if there was a downgrade or UCR allowed amount fee was reduced). Then you take the dollar amount to consider at the percentage of coverage, and this determines what the insurance will pay. You then take the full fee you charged and subtract the amount the insurance will pay, and this is the patient co-payment. Example: Posterior Composite Filling fee $100.00 Alternate Benefit of Amalgam fee $70.00 (Fee insurance considers for payment) $50 Deductible - $50.00 Amount considered for payment at 80% = $20.00 80% insurance payment= =$16.00 Filling Fee $100.00 =Insurance Payment $ 16.00 =Patient payment $ 84.00
For benefits with age limitations like fluoride and orthodontics. Are we required to take the write off for in network plans or can the patient be billed full fees? My practice is located in Florida.
Great question! If your state has a fee capping law (non-covered benefit legislation) but defines a covered service as “a service in which benefit would be available,” but a limitation of the plan was applied resulting in no payment or payment of an alternative benefit, then the PPO can control your fee because the service is considered a covered service, it was just not reimbursed.
Check out DCS' Fee capping article for more info: www.dentalclaimsupport.com/blog/fee-capping-dental-insurance
For downgraded fees, the deductible doesn’t have to be accounted for in what the insurance covers?
Hi! Thanks for your question!
To figure out what the patient's responsibility is, you should always subtract the remaining deductible amount from the allowed amount (if there was a downgrade or UCR allowed amount fee was reduced). Then you take the dollar amount to consider at the percentage of coverage, and this determines what the insurance will pay. You then take the full fee you charged and subtract the amount the insurance will pay, and this is the patient co-payment. Example: Posterior Composite Filling fee $100.00
Alternate Benefit of Amalgam fee $70.00 (Fee insurance considers for payment)
$50 Deductible - $50.00
Amount considered for payment at 80% = $20.00
80% insurance payment= =$16.00
Filling Fee $100.00
=Insurance Payment $ 16.00
=Patient payment $ 84.00