If you are a PPO provider and place porcelain crowns for cosmetic reasons—meaning the insurance company will not provide a benefit for the service—can you charge your non-PPO fees for the crowns? What about when a patient exhausts his PPO yearly insurance benefits and you have more treatment scheduled, can you bill your non-PPO fees for that work?
Insurance Solutions Newsletter tackles this issue in detail in the April issue. Since most questions involving insurance result in confusing and somewhat contradictory answers, it should surprise no one that this issue follows the same pattern.
The majority of PPO plans, including Delta Dental (ODS and WDS), limit the dentist to contracted fees for all “covered services.” This means if the plan offers a benefit or would offer a benefit if not for contractual limitations, frequency limits, or any other limitations—such as the exhaustion of yearly benefits—the doctor can only charge PPO fees.
Therefore, the porcelain crowns you do for cosmetic reasons and the fillings you place after the benefit max is reached are billed at the PPO fees. Why? These services are considered “covered” since a benefit is normally offered, even though a benefit is not paid in this example. If this doesn’t sound fair to you, you’re not alone.
Oregon and Washington are among sixteen states that have passed legislation addressing the issue of what dentists can charge for services. The politicians have come to the rescue, right? Not really. The Oregon bill states that a dental services contract (a PPO contract) cannot restrict the price that a provider charges unless the charges are “covered.” Unfortunately, the bill does not define “covered services,” so we are still facing many of the same questions.
The Washington bill defines covered services as any service where the plan offers a benefit or would offer a benefit if not for contractual limitations, frequency limits, or any other limitations. Our Oregon and Washington legislators have more work to do.
And since we’re dealing with insurance, we have another twist. Many plans today are self funded, meaning the plans are typically subject to federal and not state law. The ADA has introduced legislation to amend the current ERISA laws that govern self-funded plans, redefining the meaning of covered services and allowing dentists to charge full fees for non-covered services. Of course the insurance companies are fighting hard against the legislation.
For now, you need to read your PPO contract carefully. In most cases, you can only charge your full fee for services not covered by the plan. If you are not happy with that answer, lend your support to the efforts of state and national dental associations and contact your state and federal legislators to voice your opinion.