I’m sure many of you saw the business article published in the ADA Weekend Edition and in the ADA Finance Edition titled: “ADA Council Urges Dentists to Report Full Fee to Payers.” Don’t worry, I’m about to rip this ridiculous article to pieces.
Let me be very clear from the start. Dental Insurance Companies, commonly called “third-party” payers, DO NOT SET THEIR REIMBURSEMENT FEES BASED UPON YOUR FEE-FOR-SERVICE FEES. For the ADA to say otherwise is unbelievable to me. They should know better. It’s articles like this that drive ADA membership down, because those of us in PPO-driven states know this article to be anything but true. My goodness ADA, dental insurance companies set reimbursement fees based upon profit and loss – how much comes in via premiums and how much is paid out – guarding their set profit margins.
Well, let’s look at this article in depth, shall we?
The teaser on the front page read as follows:
ADA council urges dentists to report full fee to payers
The ADA Council on Dental Benefit Programs said, “dentists should report their full fee when submitting dental claim forms for services reported to third-party payers.” The council also “encouraged dentists to review PPO agreements annually and to discuss potential increases in fee schedules with payers.”
I’m really wondering why the ADA is urging this reporting to dental insurance companies. Those of us who have been PPO providers for years know our reimbursement fees haven’t even come close to keeping up with the cost-of-living index. The main and only reason third-party payers want us to submit our FFS fees is so they can show their clients the remarkable discount they receive by purchasing their dental plan, versus not having dental insurance at all. Is the ADA touting this strategy because they receive a load of money from the dental insurance companies from the leasing of the CDT Codes? That’s the only reason I can come up with, because I typically follow the dollar when it comes to understanding the reasons people do what they do.
The second sentence is interesting, because our office has received higher reimbursement rates than some neighboring dentists who submit their “full-fees”, and yet we have sent in our contracted fees for over 20 years. One more statement that should make your blood boil is that after two major investigations over the last 18 years, insurance companies have stated to us that they have no idea where the thought of sending in our FFS fees has any impact on their reimbursement fees. Those are the words of PPO leadership, not ours.
Anyway, let’s move on. Next we read, “It is always appropriate to report your full fee.” Wait, on the teaser page they state, “The ADA Council URGES dentists to report full fees to payers.” They start out with “urge” and then move to it being “appropriate” to send in your FFS fees in the beginning of the main article. I love the movement from a direct command of “urging” to the lesser position of appropriateness in sending in those FFS fees. It’ reads like this, “Dental Insurance Hub: It is always appropriate to report your full fee.” Then comes the editor’s note which reads, “Dental Insurance Hub is a series aimed to help dentists and their dental teams overcome dental insurance obstacles so they can focus on patient care.”
May I humbly suggest to the ADA that they get more aggressive in going after third party payers with legislation that prevents them from attempting to control the quality of patient care in dentistry? Like down-coding, bundling procedures, forcing dentists to do free dentistry via imposed write-offs that actually break state laws with non-covered services, let alone the very contracts we sign with these PPO Plans. That’s right people, as most of you know, dental insurance companies change their contracts/handbooks on us “at will” and bully the unknowing dentist into writing off procedures they don’t have to if they only knew how to push back.
Now then, in defense of the ADA, if they get the DOCs Act passed by 2024, and its verbiage is not “watered down” to appease the dental insurance companies, that would be a huge win for the ADA, and worthy of being a member. But, they’ve been trying to pass this law for over six years now. This is what I mean about the ADA needing to be more aggressive in protecting dentists against third-party payers. How is that done? It’s simple, it’s called protective legislation, like what we have done here in Utah.
Let’s read further:
“The ADA Council on Benefit Programs is recommending that it is always appropriate to report the full fee in the dental claim form for each service reported to a third-party payer. A question frequently asked of the ADA staff is what fee should dentists put on the dental claim form, said, Mark M. Johnston, D.D.S., chair of the council’s Dental Benefit Information Subcommittee. My full fee or the plan’s maximum allowable (network) fee? A full fee is the fee for a service that is set by the dentist, which reflects the costs of providing the procedure and the value of the dentist’s professional judgment. A contractual relationship does not change the dentist’s full fee. Therefore, the council recommends that it is always appropriate to report the full fee.”
Can I just remind all of you that the large majority of dentists set their fees by utilizing “fee surveys” from the ADA or their dental suppliers. Heaven only knows where they get those fee surveys from. Let me tell you where most dentists do not set their FFS fees from: the direct operating costs required to complete the procedure, plus a 30-50% corporate profit margin. I hear colleagues say, “Rob, I can do that with my FFS patients, but it’s impossible to do it with the PPO plans I take.” That is simply not true. You absolutely can be profitable on the majority of procedures on PPO dental plans if you know what you’re doing, and I’m not talking about cramming your schedule and busting the backs of your hygienists and team members. This is why our dental business training courses have been packed with dental teams who are tired of being misled by so many in our industry. Click on the link below for information on the best guaranteed dental business training in dentistry: https://www.mypracticemybusiness.com/dental-business-courses/
Let’s continue the reading:
“It is always surprising to me how many dentists do not submit their full fee on a claim,” Dr. Johnston said. “It may be due to many factors, including a front office person that does not like to deal with the practice management system’s accounting package, so they just submit the fee that they know will not require any write-offs, making their job easier. The doctor may not be aware of the reduced fee submitted by the team member and then wonders why there are never any increases in the reimbursement.”
My hell, what planet are you on my dear colleague? First of all, we dentists throw these wonderful front office people in those management positions with no business training. The majority of those wonderful front office peeps come to us with little to mostly zero formal business training, and we demand the world from them. If they want to follow business accounting principles that are followed in every other business worldwide by actually billing out near exact procedural totals so that they know exactly what they should be collecting from the patient and the PPO plans, I am completely supporting them in doing so. It makes their jobs so much easier, and heaven only knows they need more accounting procedures that are fast, simple, and easy.
Two more points. First, reimbursements are not increased by sending in your FFS fees. All of us who are, and have been, taking PPO plans know this simple truth as stated earlier. Second, following accounting principles of exact billing of patients on PPO plans reduces the temptations of fraud and embezzlement from our wonderful front office peeps. You should know that my ADA friends. Most business trained dentists would certainly agree that antiquated accounting principles of unknown write-offs from EOBs due to submission of FFS fees to third-party payers creates an environment for fraud and embezzlement.
Finishing the article we read:
“The council is also reminding dentists of the importance of conducting an annual review of their signed PPO agreements and talking to payers about fee increases. The ADA’s contract negotiations toolkit may come in handy if dentists want to try to renegotiate contract terms and provisions, including network fee schedules.”
Allow me to let you in on a little secret ADA leadership: fee negotiations are done every two years, not annually. And…many dental plans no longer negotiate. Unbelievable. You are making it harder for KOLs like me to convince non-members to join the ADA. For the love of all that is dental, please come up to speed on PPO!
One more additional thought: insurance companies are lowering negotiated fees to LESS than what was agreed to as a financial business strategy that is rarely caught by front office teams. How would you catch this if you billed your FFS fee? We caught TWO insurance companies doing this last year and when we called them out on it, they stated there was a “bug” in their system, and they would fix it and send us another check to account for the percentage they should have paid. How many offices are unnecessarily writing off or reducing services because they are billing their FFS fees, and not seeing this little insurance tactic? You would almost never catch this little bait-and-switch tactic dental insurance companies do if you were sending in your full fees. Chew on that one little accounting problem.
As for myself and all the dental teams we train each year, we will be sending in our contracted fees for accuracy in accounting and to maintain our ability to catch third-party payers when they attempt to pay less than our contracted amount.