PPO Dental Plans: What You Need To Know

Unlike conventional indemnity plans, PPO plans require participating doctors to accept significantly reduced fee schedules and endure limitations on reimbursement. This has resulted in a reduction in income for many practices.

Furthermore, PPOs attempt to control the cost of procedures by requiring doctors to abide by the least expensive alternative treatment (LEAT). In many cases, the insurance payer has the right to change the reimbursement (remap) for a service to a less expensive, clinically acceptable, alternative treatment.

Many participation agreements contain limitations; however, a payer cannot dictate the treatment provided. The reimbursement of the treatment should never direct the care recommended by the doctor, or accepted by the patient. The ultimate decision to accept a recommended treatment plan lies with the patient. The doctor’s responsibility is to explain the patient’s problem, the necessity of the treatment, the pros and cons of all available treatment options, as well as the risks of foregoing treatment.

Insurance doesn’t begin to cover it

Today’s patients are better educated and have higher expectations than ever. Patients generally believe the treatment they need and want should be covered by their insurance plan, without question. Many patients expect that all of their dental needs should be paid by their insurance, with no out-of-pocket payment. The challenge for the doctor and team is to help the patient understand that all treatment is not covered, and that out-of-pocket expenses may be substantial. If the patient wants a higher level of care, more esthetic restorations, or the implementation of more modern techniques, the PPO will most likely not reimburse it. Only the most basic level of care is reimbursed.

Education is the key to treatment acceptance. The patient must understand that dental insurance is not intended to pay for 100% of the cost of all treatment. Patients must be informed that there is a difference between what is covered by insurance and what is needed to restore their health. The patient needs to understand the diagnosis, the recommended treatment, and the risks and benefits of the treatment. Hopefully, after an understanding is reached, the patient will accept the treatment plan and agree to pay for the needed treatment, regardless of PPO reimbursement coverage.

Many dental practices believe that, as a participating provider, they are obligated to accept a reduced reimbursement with no recourse. However, in most cases this is not true. By utilizing optional services, the practice and the patient have choices that allow the patient to select the treatment plan they want.

What are considered optional services?

Procedures that are not covered benefits under the terms of the dental contract are considered optional services. If an enrolee elects to have an optional service, a claim should be submitted, and the provider’s office will review the procedure. If the procedure is an alternative to a covered service, they may make a payment based on the allowed amount for the covered service.

For example, if your benefit plan allows for amalgams only even though a metal or porcelain inlay is suggested by your doctor, Delta Dental of Tennessee will pay for only the cost of the amalgam.

Many payers have adopted a similar definition of optional services and allow the provider to balance bill (i.e., bill the difference between the “basic” service and the “optional” service) the patient for the “upgraded” treatment. Many payers also require approval to balance bill the patient.

It is important to discuss the limitations of the insurance plan and the benefits of the recommended service over the LEAT service, and to explain that the explanation of benefits (EOB) may be confusing and has the potential to be inaccurate. The practice should collect the patient portion up front. This includes any copayments, deductibles, and the difference between the basic benefit and the agreed-upon optional service.

It is strongly recommended that the practice contact a benefits representative at the PPO plan before performing any optional services. See “What to ask your benefits representative” for questions that should be answered before beginning the billing process.

In most cases, documentation of the discussion and the acceptance of the optional service would include the following:

• A description of the optional service
• A description of the basic service
• An explanation of how the optional service will appear on the patient’s billing statement and on the EOB (i.e., predetermination)
• An estimate of the anticipated insurance reimbursement
• The cost of the optional service recommended
• Explanation of the difference in cost between the basic (LEAT) service and the optional service
• Benefits and risks of the service
• The estimated out-of-pocket responsibility of the patient for the optional service
• Acknowledgement of the opportunity to ask questions
• The patient’s signed acknowledgement and acceptance of receiving the optional service
• Signed approval of the out-of-pocket expenses and agreement to pay the difference

Claim submission for optional services

Report the CDT codes that most accurately reflect the service provided. Always list the full practice fee. Never list a reduced fee on the claim form, even if the doctor has agreed to the lower in-network fees. The fees submitted on claims are used to calculate UCR (usual, customary, and reasonable) fees and are averaged with the other doctors in the network. Reducing the submitted fee would reduce the network average and could jeopardize future fee increases.

If the patient is covered by multiple plans, coordination of benefits (COB) may allow the practice to receive up to its full practice fee. The practice may keep more than the lowest contracted fee, up to the full practice fee, when all plans have paid. If the submitted fee is reduced to the scheduled PPO fee, the practice may not benefit from COB. Submitting full practice fees allows the practice to (1) track all write-offs and (2) to benefit should the PPO increase fees.

The remarks section (Box 35) of the 2012 ADA Dental Claim Form indicates that the patient understands the service is optional and has agreed to the additional charge. Be sure to include this comment within the 80-character limit guaranteed to reach the payer. Attach a copy of the disclosure and agreement, signed by the patient, agreeing to pay for the optional service.

If the practice is unsure of the payer’s policy, submit a predetermination with the supportive information listed above prior to providing treatment. Once the predetermination has been received, the processing policies for that particular plan may be determined. Should the predetermination provide incomplete, confusing, or contradictory information, contact the payer for clarification. It is often helpful to speak with one of the payer’s dental benefits consultants for more information about processing policies for optional services.

What to ask your benefits representative

• What is your company’s definition of optional services?
• Can we balance bill the patient for optional services?
• Ask about the plan’s policy on the specific service in question. These optional services may include, but are not limited to:
  – Clear aligner orthodontic therapy
• Porcelain crowns in “non-esthetic” areas
• Acrylic clasps on partials
• Composite restorations instead of amalgam restorations
• Gingival irrigation and desensitizing
• Laser therapy (LANAP)
• Same-day indirect crowns
• Implants rather than partials or bridges
• A full-coverage crown for a cracked tooth that does not meet the payer’s criterion for full coverage
  – Indirect inlay restorations rather than direct restorations (amalgam or composite)
• Is the ability to balance bill for optional services company-wide or plan-by-plan?
• How should the practice document the discussion and acceptance of the optional service with the patient?
• How should a claim for optional services be submitted?
• Some plans ask that the optional service be described using a Dx999 code.
  – Some plans review the supporting documentation to determine the reimbursement and patient responsibility for the provided service.
• What documentation should be provided with the claim (predetermination) for optional services?
• Will the explanation of benefits (EOB) accurately identify the patient’s true responsibility?
• Who should be contacted if there are concerns with the processing of optional services?
• Should there be any issues in the future, make note of:
  – The first and last name of the contact person at the provider relations office
  – The date and time of the conversation
  – A brief outline of the questions asked and answers provided