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To Claim or Not to Claim — That is the Question

Dental Insurance Today — October 2020
During a recent webinar for the American Dental Association (view video on YouTube), I referenced the unethical as well as potentially illegal practice of not disclosing patient-billed services to either participatory or non-participatory benefit plans. In other words — make the patient pay for something out of pocket without submitting for it on a claim for benefits on behalf of the patient.

First things first — there is absolutely no difference in what and how to globally bill a patient and their benefit plan whether the office is in or out of network. The only differences are the end result dollar amount collectable for the completed service and the actual dollar value of the coded as well as completed procedure.

Run from those who draw an in or out of network distinction with their actual coding advice.

Don’t get me wrong. As I shared in the webinar, “you make money by participating in a contractual benefit plan only when those reduced fee patients are filling previously empty and open available chair time.” That is it…

Surprise Medical Billing

Many states as well as our federal legislature are addressing this issue under the public outcry of “Surprise Medical Billing.”

It is a professional travesty to see and read from so-called “experts” on various blind social media platforms who teach the manipulative dishonesty of tricking a patient into signing a nondisclosure HIPAA form saying they don’t want selective “upgraded” services billed to their benefit plan. I’ve seen these upgrades identified as everything from thermal pulp protection with direct restorations to porcelain shoulders, buildups and the ever popular “we can use a higher quality lab or material but your insurance won’t pay for it.” I could go on for days with a laundry list of unscrupulous “add-ons” but that is for a very different time, place, and audience.

Somehow, it is getting to be disgustingly more commonplace to justify securing additional profit hidden under the ruse of superior quality, when in actuality, it is merely ripping off the patient and their plan, all hidden by the smoke and mirrors of HIPAA .

Face it, the only reason it’s not being actually billed and disclosed to the plan is that the questionable service is, in fact, part of another completed procedure, and if it were on the claim, the plan would say that the fee for the service is not collectable from the patient. You don’t make money with a participatory PPO or non-participatory plan by directly charging the patient for so-called upgrades.

So, when do you not submit a benefit claim for a “service or procedure” charged and paid for by the patient?

Next in order is truth — the nondisclosure (or order not to bill the benefit plan) has to be at the patient’s request and initiation — not the provider or financial recipient of payment. So please don’t think about hiding the necessary language in and about your routine patient paperwork. In the world of health and medical insurance, the nondisclosed services are specifically identified in the documentation by signature and date.

Examples of potentially appropriate, patient-initiated nondisclosures could include: genetic susceptibility testing, addiction therapies, off-label prescription pharmaceuticals, behavioral health medications, gender specific surgeries with associated ancillary services… to name but a few. With all of these examples, it is easily concluded that the patient is clearly seeking justifiable confidentiality and privacy.

With the limited scope of dentistry and dental services, such patient requests for similar privacies and confidentiality would rarely exist. All too often, the issues being brought to the attention of the benefit industry and regulatory authorities are most often merely manipulative techniques to increase patient “out of pocket” payments for fragmented dental coding.

Long story short — Use of a HIPAA directed nondisclosure is not an appropriate dental office profit enhancing tool.

Tom Limoli
Tom Limoli
“The Nation’s Leading Reimbursement Expert”
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