Dental benefit plans1 seeking to limit the fees professionals are permitted to ask for and collect is not really very surprising when one thinks like a business person.
The companies that build these plans and sell them are businesses, and just like your dental business might decide to join a buyer’s club to lower the cost of an essential “supply” and increase profit, they seek to find dentists and corporations owning dental practices that will sell them the essential item they then re-sell – professional services – at a lower rate and raise profits. Being angry because they do this is not productive since it flies in the face of what each of us do everyday if we own a business. It’s just business. The issues created are business issues when one takes that viewpoint.
Because this is healthcare, I must state for the record that there are also professional and ethical issues created. Still, given fair consideration of these professional and ethical issues, casting defined dental benefit plans as evil simply because they do what businesses do and have always done is, in my humble opinion, a bit disingenuous of us as business owners.
The professional and ethical dilemma that I encountered when I was involved with a defined benefit plan several years ago – the right of the patient to select the care they would like to have and choose to pay for willingly regardless of what their defined benefit plan has negotiated with the “providers” to give them – is an issue that eventually drove me away from a relationship with defined dental benefit plans beyond sending in a report of what transpired in my office and the fees associated with that.
If you decide to participate (be contracted) with a defined dental plan, you have already agreed to a preset fee for every service the defined benefit plan lists as a covered service. This was a business decision and drives what you are able to offer the patients in that defined plan. In some states you have also agreed to a preset fee for services that are not covered by the defined benefit plan if the plan elects to limit those fees also. In that case, you have agreed to ask and collect for preset fees for all of those non-covered services, too.
In a July 2013 listing from the ADA, 33 states had laws in place that prevent dental defined benefit plans from limiting the fees you may ask for and collect for non-covered services. There are an additional two states that have added legislation since then for a toal of 35:
- New Mexico
- North Carolina
- North Dakota
- Rhode Island
- South Dakota
If you practice in one of these states and you are contracted in a PPO plan, that plan may not limit the fees you ask or receive for non-covered services. If you want to see the details, download this PDF from the ADA 2013 report, "State Laws - Prevent Capping of Non-covered Services." 2
That means that if you practice in Alabama, Colorado, Delaware, Florida, Indiana, Maine, Michigan, New Hampshire, New Jersey, New York, Ohio, South Carolina, Utah, Vermont or West Virginia, and are contracted with any defined dental benefit plans as a PPO “provider,” you may be limited on the fees you can ask and receive for services that are not covered by the defined benefit plan. (If you are aware of any difference between the information the ADA currently has and the law in your state, I would be very grateful for that information so I can pass it on.)
Reduction of choice
One of the professional and ethical dilemmas created by defined dental benefit plans is a reduction of the choices available to the patient and the doctor. If you, the patient, wanted to choose a different type of service and pay for it, the doctor could be in violation of the contract with the defined benefit plan by accepting that payment for the different level of service.
This dilemma could also arise even if you expected and wanted no benefit for the service provided. If you chose to opt out of your defined benefit and just get what you want for yourself, it could place the doctor in violation of the contract as he/she might be obligated to inform the plan of all services provided for you.
In 2013, HIPPA changed that. According to the ADA, patients can choose to opt out of a benefit, direct the doctor not to inform their benefit plan, and pay in full for the services themselves. Even if the PPO contract obligates the doctor to inform the plan of all services, that contract cannot require you to violate applicable law. 3
If you live in a state where patients are not free to exercise their right to have something different than what a defined plan allows, know that the ADA is actively working to educate legislators to enact laws that give choice to the patient. Write or speak with your representative to show them that adding such freedom can only improve the impact of any assistance received through a dental defined benefit plan. We do not need to work against these plans, but we need not be shackled by their choices regarding what our patients need and what our patients want.
- Some would call these plans “dental insurance,” but they are not dental insurance – as most of you know that is a topic near and dear to my heart. For more on this, read my article on why dental insurance does not exist.
- ADA sheet “State Laws – Prevent Capping of Non-Covered Services” July 10, 2013
- ADA response to inquiry: Patients can opt out of coverage and pay themselves, rec’d 5.9.16