Inclusive and Not Billable to the Patient … What Now?

Your patient comes in to the office for their regular cleaning and you find yourself billing for panoramic and bitewing x-rays on the same day. Why? Well, because the patient needed them and you are following the “standard of care” that your dentist is held accountable for. However, you (once again) receive that dreaded EOB that combines those services to a “full mouth series” (FMX). The EOB alludes that you should be writing off the difference. Sound familiar?

Yes, it’s easier to simply write-off the balance due from the patient and follow the EOB verbiage…but what are you telling your patients when you back down? That you don’t know your job? That you will write things off if they “bully” you to do so? That the insurance companies care about them? That you need constant “oversight” so you don’t overcharge them? And my favorite, “We do free dentistry here”.

There are four issues with these unethical and regular protocols done by almost all insurance companies in our state: 1. Have you looked at your contract to see if you are required to write off the downgrade or bundle the services? As of right now, we have only seen one insurance company continue to promote these philosophies. 2. The ADA considers “bundling” to be potentially fraudulent. Heck, they even give the above example of downgrading x-rays in that statement!1 3. Our wonderful, amazing new Utah law, now to be called the “Network Leasing, Downcoding and Bundling

Protections” Law, PROHIBITS insurance companies from using “Bundling or Downcoding” as a way to change a covered code to “non-billable” to the patient. Oddly, by regularly downgrading x-rays in the example above, the insurance companies are both downcoding and bundling. 4. As all of you know, it’s not just x-rays. There are many examples of downcoding and bundling that we are currently confronted with.

So... how do you fight back?

The first step is to check and see if the insurance plan is “selffunded” or not. Unfortunately, the only way to check is to call the insurance company directly. Once you’ve established the plan as being “self-funded”, flag it for all current and future patients with that plan so you’re not “duplicating the work”. Like it or not, self-funded plans are not required to follow state law, and in those cases, follow your contract. I emphasize again to read your dental contracts…you’d be surprised to see what’s not in there.

The next step is to simply collect the difference from the patient and stop writing it off. Yes, the EOB is wrong. We’ve

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seen it before with other CDT codes showing “zero” patient responsibility, yet we collect, knowing it’s wrong (Fluoride, anyone?). Many times, I simply pick up the phone and let the patient know that the insurance paid all but a little bit from their x-rays and collect over the phone. Most patients sigh, tell us how much they hate their insurance, and ask if we can take their credit card.

“But what if they use their EOB against us?”, you ask. Yes, there will be a few patients that wave their EOBs in your face as though it is the “foremost authority” on proper billing. You know…those patients are the ones that think you don’t know how to do your job. The ones who question everything you charge out on the ledger. For those ones, there’s something “extra” for you to do, and if you want to make the rest of your future interactions with those patients better, you’ll want to do this immediately. First thing to do: pick up the phone and call the insurance company directly.

Before we start “the battle”, let me emphasize that the first person you talk to will be a “tier-1” representative, whose job is to read their “general policy” and get you off the phone as fast as possible. They do not know state laws. You do now. Teach them.

Step One: “Hello, my name is_______ and I’m calling from Dr. _____’s office and I would like to know WHY I’m being told to write off this downgrade or bundle this procedure.” Step Two: “You consider it to be ‘Inclusive’/not billable? That’s fine, but where in my contract does it state that I’m supposed to write the service off?” Make them show you. Step Three: Let them know that there is a new Utah Law that contradicts the verbiage on the EOB and they are breaking the law. State law supersedes contractual agreements. Explain what part of the law is being broken. Examples are: