- When insurances combine multiple fillings on one tooth, can we bill the difference?
Depends! If the dentist is non-par and the patient’s plan states that the company will reimburse the patient for multiple surfaces restored on a tooth as one restoration, the dentist can bill the patient for the balance between the dentist’s fee and the benefit – as the dentist would for any other service. If the policy does not contain a qualification regarding the benefit determination limitation – and even if it does - the dentist should appeal the adjudication.
- When working with dual insurances, does the lowest fee always apply? What if one of the insurances doesn’t have a fee schedule and pays at the office UCR? What to do if both insurances pay and patient ends up with a credit?
The “fee” is what the dentist charges the patient and expects to collect – not the third party’s allowable benefit. The fee that applies is the dentist’s charge to the individual patient. If the dentist is par with either plan, the lowest contracted fee applies. The dentist (actually the patient) can never recoup more than the dentist’s actual charges for the service. Each plan will define its policy with respect to coordination of benefits.
- Does birthday coordination rule apply right away? What if a person gets a secondary insurance midway through the calendar year?
The “birthday rule” is not uniform among plans. The terms of the patient’s policy determine whether it applies. Whenever a patient purchases or is enrolled in any plan, the rules of the plan apply and would supersede previous coverage.
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I don’t understand the question….?
- Billing for incomplete treatment. Ex. Patient never returned to finish root canal.
Patients are eligible for reimbursement from most plans only when a procedure is completed. [A dentist should document in the chart efforts to contact patient in writing about the importance of completing treatment and urging the patient to return.] If a claim is submitted to the patient’s carrier, it should indicate that the procedure is “in progress” and that the patient is not returning to the practice (some patients actually die!). Some companies will provide a benefit to the dentist; however, it is the patient who is responsible for the fee for all services rendered to date and often the dentist must bill the patient in this situation.