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ISSUES RELATING TO THE COLLECTION OF CO-PAYMENTS BY CALIFORNIA DENTISTS

 
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When a dentist, who is an approved provider in a dental insurance plan, waives a “co-payment” on a patient for treatment, does the waiver of co-payment violate any California laws?

Answer: No. Refer to the attached Office of Attorney General Opinion dated October 16, 1981.

When a dentist who is an approved provider in a dental insurance plan waives a “co-payment” on a patient who is part of a dental insurance plan, does the waiver of the co-payment constitutes fraud or misrepresentation under applicable California laws?

Answer: No. Refer to the attached Office of Attorney General Opinion dated October 16, 1981.

When a dentist waives a “co-payment” on a patient who is part of a dental insurance plan (whom the dentist has membership in) which requires the collection of co-payments, does that violate the provider agreement that exists between the dental insurance plan and the dentist?

Answer: It may, depending upon the subjective opinion of the dental insurance plan. Dental insurance plans take into consideration whether the practice has taken reasonable attempts to make collection of the co-payment such as having A) written payment policies in the practice; B) having written fee agreements with patients; C) monthly statements are provided to the patient requesting payment; D) custom and habit in the dental office for front desk staff or the treatment coordinator asking for payment when the patient presents at the office; E) having an office protocol of reviewing the accounts receivable printouts and following up with patients in an attempt to collect the outstanding sums owed to the dentist. The best practice is to collect copayments up front before care is provided.

Do dental insurance plans have a threshold requirement of the percentage of co-payments that constitute a reasonable co-payment collection rate?

Answer: It depends on your dental insurance contract to determine your insurance plan’s copayment collection rate requirements. If you need clarity, it is always best to contact your dental insurer and obtain an answer from them (but make sure it is in writing or send a confirming email to the customer service representative who provides you with the answer!).

Are there reasons why, in the judgment of the dentist, a patient’s balance that is owed to the practice is written off which may or may not include the co-payment amount of a patient who is a member of a dental insurance plan?

Answer: Yes. Dentists often write off balances owed by patients for one or more of the following reasons: 1) if dentist has an understanding that the patient was unhappy with the treatment, it is often a smart risk management move to write off the balance; and/or 2) empathy for the patient if they have had some type of personal difficulty such as losing a job, having a medical condition, being a fire victim, losing a loved one, etc.

Are there good reasons for NOT pursuing collection of a balance owed by patients?

Answer: Yes. Dentists often do not pursue collection of balances owed by patients for one or more of the following reasons: 1) concern that collection action might trigger a malpractice claim; 2) empathy for a patient who has had some type of personal difficulty such as losing a job, having a medical condition, being a fire victim, or losing a loved one; 3) concern that collection actions will trigger a nasty Yelp review or internet-based negative comments; or 4) concern that collection action will damage practice goodwill because a patient will bad-mouth the dentist or practice.

Please note: These statements do not apply to Medicare, Denti-cal or any other federal insurance or benefit programs.