Potential for Fraud: Submitting the Proper Fee

Reporting the correct fee on a dental claim form is key to receiving proper reimbursement and reducing risk. It has been reported that some payers are instructing dental practices to report the contracted fee on claims, stating that reporting the full practice fee is fraudulent. Be aware that this is incorrect. Always report the full practice fee (or actual fee charged).

The ADA House of Delegates issued Resolution 44-2009, Statement on Reporting Fees on Dental Claims, which provides guidance on the appropriate entry for Box 31 of the 2012 ADA Dental Claim Form. The following statement is contained in the claim form instructions:

Statement on Reporting Fees on Dental Claims

1. 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.
2. A contractual relationship does not change the dentist’s full fee.
3. It is always appropriate to report the full fee for each service reported to a third-party payer.

There are several benefits to reporting the full practice fee on all dental claim forms:

• Submitting the full practice fee on all claims will ensure that the practice benefits from any fee increases. Payers reimburse the lesser of the submitted fee or the contracted fee. If the payer has increased contracted fees and the practice submits an old, lower contracted fee, then the practice will not benefit from the fee increase provided by the payer.
• Some payers track practice fees to determine if the doctor is eligible for a fee increase. If the practice consistently submits the contracted fee, the payer may not increase the contracted fee.
• Most payers set UCR (usual, customary, and reasonable) fees by analyzing the fees submitted on claims in a given geographical area. Submitting full practice fees provides the payer with accurate fee data. Claims consistently submitted with lower, contracted fees may negatively impact any potential future fee increases.
• Reporting the full practice fee will allow the practice to analyze a given PPO or contracted payer. This analysis may include tracking required write-offs, patient responsibility, etc.
• If the patient is covered by more than one dental plan, submitting the full practice fee may allow the secondary payer to coordinate benefits based upon the full fee. There are a few plans that will coordinate up to the full fee submitted on the claim, which may result in a reduction in the required contractual write-off. This may even allow the dentist to collect up to the full fee.

Note: Practice management software typically allows for the entry of multiple contracted fee schedules. Each contracted fee schedule entered should only be used to calculate and communicate patient responsibility during treatment plan presentation and to confirm financial arrangements. Contracted fee schedules should never be reported on submitted claims, even when they are entered in the practice management software.