How to Define and Charge for Non-Covered Benefits

Non-covered benefits, in light of the Affordable Care Act, have become a bigger issue for PPOs and dental practices looking to provide the best care possible. What are non-covered benefits, and how can you define and collect for them?

First: Know Your Laws

Depending on the state in which you are practicing, the laws relating to non-covered benefits might provide different limitations and requirements than what we discuss in this article. We encourage all dental practices to research the exact details about non-covered benefits and limiting fees for the state that the practice operates in.

What Are Non-Covered Benefits?

A covered benefit is any procedure that a dental plan is obligated to pay based on the contract that the enrollee signed. A non-covered benefit is anything that a plan does not cover and never pays for.

Beginning in the 2000s, dental plans increasingly made moves to dictate fees to dentists contracted with them for procedures that plans would not cover. In simpler terms, this means that PPOs named a price for services that were not covered, thereby setting a marketplace standard. Non-covered benefit laws prevent insurers from making dental providers offer those benefits at a discount, even when the services would not be covered.

Currently, many states have laws on the books that stop defined benefit dental plans from limiting the fees that dental practices can request and collect for non-covered services. If you practice in the state of Maryland, a PPO plan cannot limit the amount or number of fees you ask for or get in exchange for non-covered services.

In a small list of states, including Delaware and New York, the list of fees you can request if you are contracted with a PPO is limited. That means that, if patients receive a non-covered service, the dental practice will only be able to charge so much for the procedure without breaking the PPO contract.

Charging for Non-Covered Benefits

Charging for non-covered benefits is straightforward when the service is explicitly not included in the dental plan. However, covered services that exceed an annual maximum or a time limitation are still not considered non-covered benefits. Even though the plan will not be contributing anything to cover the service, the PPO contract requires you to charge the same total amount to the patient.

If you need to bill a patient for a service that the plan does not cover or will not pay for, you should decide whether or not you would like to extend a discount based on customary fees. Dentists cannot charge patients more than the customary rate for services (non-covered or covered), but you are allowed to offer a discount if you would like to. This should be done on a case-by-case basis and is relatively common with long-term patients experiencing non-coverage due to a delay or annual maximum issue.

Negotiate Your PPO Reimbursements with Help from APEX

If you want to know more about PPO contracts and reimbursement rates, our experts can help. Contact our team today by calling (410) 710-6005. We look forward to working with you to make your practice a more profitable place.