THE ADA PRACTICAL GUIDE TO EXPERT BUSINESS STRATEGIES 7 two, three or four plans can radically effect how benefits are determined. Patient responsibility can get lost in the mix and must be accurately communicated to the patient. Usually, the secondary policy will not accept a claim until after the primary claim is paid. Then the secondary policy will often require a copy of that payment information, known as an explanation of benefits or EOB. The patient always receives the benefit from the lowest of all contracted fee schedules when the doctor participates with any or all of the plans involved. This is the “patient responsibility” amount. The fact that a plan is primary or secondary does not alter the fact that the patient receives the benefit of the lower of the fee schedules. Thus, when participating in a plan that covers the provided service, the practice cannot charge the patient any more for the service than the lowest contracted fee, but the practice should be able to collect from secondary coverage up to the full fee for a procedure. Full charges should be listed on all claims. Practice charges represented to all carriers (primary, secondary, tertiary, etc.) should be the full, unrestricted fee. Write-offs should only be calculated once ALL plans have paid the claim in full. All carriers modify charges according to plan limitations. Due to variations in expected reimbursement, the final write off can only be made after all claims have been paid and posted to the ledger card. When payments are received from multiple plans that coordinate (even though that amount is greater than the lowest contracted fee) the practice may keep up to the full fee for the service. In cases where multiple payments are received and the total paid by all plans exceeds the full fee charged for the service, then overpayment must be returned to the payer(s). Thus, a practice could participate in several low fee plans, yet receive its full fee under some circumstances. Keep in mind that coordination of benefits rules are determined by state law, not by dental plan. Therefore, the rules may vary from state to state. However, if a state law is silent on the subject of coordination of benefits, then the contract may determine whether the insurers will recognize or respect the coordination of benefits. Consult an attorney familiar with the laws of your jurisdiction for advice on the laws in your area. Co-pay and Deductible Forgiveness First, according to its Principals of Ethics and Code of Professional Conduct, the ADA considers the practice of co-pay forgiveness unethical. Second, the vast majority of participation agreements prohibit it. You must refer to each of your participation agreements for the specific language. Also, state legislation governing insurance law prohibits it in one form or another. All federal plans prohibit co-pay forgiveness. So, the best course of action is to seek legal advice regarding the specific language as it applies to your state. Offering Discounts Discounting a charge from time to time is generally acceptable. For instance, a crown charge is $1,000. However, the patient is given a 15 percent discount since the treatment is for ten crowns. As another example, a relative is given a 30 percent discount. If a discount is given, and the patient has insurance, then the actual charge paid by the patient should be reported to the insurance company to ensure proper reimbursement, not an overpayment to the patient. If the practice reports the full fee on the service line of the claim, additional information must be provided to inform the benefit plan that a discount was provided to avoid a misleading claim.