Dental Insurance FAQ
The following is a typical plan design for a PPO plan:
100% coverage for preventive and diagnostic services*
80% coverage for basic restorative services
50% coverage for major restorative services
50% coverage for orthodontics subject to separate lifetime maximum of $1,000
$50 annual deductible applies to all services except preventive and orthodontic $1,000 annual maximum for all services except orthodontics (*percentages are applied to the maximum allowable fees as determined by the insurance carrier)
The dental insurance carrier will not allow me to increase my fees with their plan. What can the ADA do for me?
Federal anti-trust laws prevent the ADA from negotiating fees on behalf of dentists; however, dentists are free to negotiate fees on an individual basis. The ADA legal division has information on anti-trust concerns available to members.
My patient was paid directly by the dental plan even after he/she authorized assignment of benefits on the dental claim form to my office. What can I do?
Staff has been working with state dental societies to pass assignment of benefits legislation aimed at preventing this exact scenario, and we are aware of 23 states that have passed such legislation. If your state has not passed this type of legislation, it is recommended you contact your state dental society for assistance
If I participate with two PPOs, which fee am I allowed to charge the patient? The higher fee, if secondary, or the fee allowed by the primary carrier?
Many factors can determine what fee a doctor can charge in this situation, including but not limited to state insurance statutes, participating provider agreements and the carriers processing policies. It is recommended that you check with the carriers to determine what fee you are ultimately allowed to bill the patient. You should also check with your state dental society to determine if there is legislation in your state that addresses which fee should be allowed.
The dental insurance carrier changed the procedure code that I submitted on the dental claim form. Is this legal?
There is an important distinction between changing the submitted procedure code and paying for a different procedure code based on the plan’s design and processing policies. It is not uncommon for third-party payers to acknowledge the code submitted, but to then pay an alternate benefit. They are allowed to do this. What they cannot do is substitute a different code without acknowledging the original code submitted. You should submit the procedure code(s) that most accurately describes the procedure performed. Any pressure from a payer for you to submit a different code other than the one that most accurately describes the procedure you performed, in order to conform to their payment policies, should be aggressively resisted. Additionally, if you feel the claim was not properly adjudicated, you should appeal the decision.
Even though the dental plan did not cover a certain procedure, the EOB indicated I could only charge the patient the plan’s maximum allowable fee and not my full fee. Can they require this?
If you signed a participating provider agreement with a dental plan that has this provision, and there are not state statutes in your state to prevent it, then you may be contractually bound to only charge the patient the carrier’s maximum allowable fee for the non-covered procedure(s). ADA staff has been continually working with state dental societies on non-covered services legislation and 40 states have passed legislation preventing third party carriers from capping what a dentist can charge a patient for a non-covered service. This means that the dentist could charge his or her full fee in the above scenario. If your state has not passed this type of legislation, it is recommended you contact your state dental society for assistance.
You may encounter situations in which a payer will allow you to charge your patient for non-covered procedures if the patient is willing to sign a consent form. The ADA has created a sample form for third party payer payment (PDF) that you may customize to meet your particular needs.
The dental insurance carrier states that an overpayment has been made to my office and now they are telling me that future payments will be withheld in order to recoup the overpayment. On what authority can they do this?
If you have signed a participating provider agreement with the dental plan, you may have contractually agreed to this. Please check the provisions of your signed provider agreement. If you are not in-network with the plan, please check with your constituent dental society for information on how this may be handled in your state. The ADA is currently working with dental insurance plans to find an equitable solution.
The dental plan keeps losing my x-rays and it is taking longer to get my claims paid. What can I do?
If you participate with the plan, it is recommended you contact your provider relations representative for assistance. If you are a non-participating dentist, it is a good idea to call the carrier to find out what happened to the radiographs you sent. It is recommended that you send duplicate radiographs to the carriers and not your originals as some carriers may not return the radiographs to your office. It is ADA policy (Guidelines on the Use of Images in Dental Benefit Programs (Trans.1995:617; 2007:419) that all images submitted to third-party payers should be returned to the treating dentist within fifteen (15) working days, but unfortunately that is not binding on payers.
Is sending images captured on a cell phone to a dental plan via text or email a HIPAA violation?
Potentially, yes. A dental practice risks a breach of patient confidentiality whenever it sends unsecured electronic protected health information over an open network. A dental practice must also consider the risks associated with storing ePHI on a device that can be lost or stolen.
Sending unsecured images and text over a cellular network is a violation of HIPAA Security Rule requirements for transmission security if the dental practice has not:
De-identified the information; OR
Done a risk analysis of its transmission security, AND
Implemented appropriate safeguards; OR
Has not obtained written authorization from the individual to send the information in an unsecured manner. CAUTION: written authorization must include the individual’s acknowledgement of any risk to their privacy. The Acknowledgement of Receipt of Notice of Privacy Practices form signed by new patients does not grant authorization for sending unsecured ePHI.
So the answer is "maybe." To avoid a breach a dental practice must be mindful of the following:
What the dental practice is sending?
How it is being sent?
What safeguards are in place, and are the safeguards reasonable, based on a current risk analysis?
If the information is not being sent in a secure manner, has the patient authorized and instructed this transmission in full knowledge of risks?
The dental practice must employ appropriate safeguards for data “in motion” where appropriate. Some examples of transmission methodologies that might work include, but are not limited to:
A secured payer web portal that permits uploading of images by trusted users
An encrypted email service
A health care image sharing app that employs sufficiently strong transmission encryption
A Direct Trust validated Health Information Service Provider
Another, far greater risk is the threat of loss or theft of the cell phone itself, especially if it stores images on its memory card that are not encrypted.
Lost or stolen unsecured devices are a major cause of large breaches affecting thousands of individuals. In turn these breaches result in complaints and expensive, highly publicized settlements and sometimes levied federal civil monetary penalties. No dental practice wants this.
Using personal phones without appropriate security features is extremely risky and could be ruinous if lost or stolen. As such, it is HIGHLY inadvisable to use a non-dedicated, unsecured cell phone or unsecured app that does not also encrypt images stored on the cell phone’s memory card or in the phone’s cloud-based storage. If a secured phone is lost or stolen, the encryption can still provide safe harbor against breach notification requirements, provided it conforms to methodologies named in the HITECH Breach Notification Rule’s Safe Harbor provisions.
If a secured, encrypted phone or app is used in your dental practice, make sure the encryption algorithm and strength have been independently tested and validated for conformance with HHS Guidance.