Should we submit our full fees or our contracted PPO fees on dental claims?

Answer

The American Dental Association (ADA) instructs dentists to report their full fee in field 31 of the current dental claim form (CDT 2011-2012, p. 130). Although contracted fees must be honored when calculating patient responsibility, they are not considered to be a dentist’s full fee. To clarify this issue, the ADA House of Delegates adopted resolution 44H-2009, which states the following:

     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. (ADA News; Nov. 2, 2009)

Dentists who submit their contracted fees on dental claims are shooting themselves in the foot for the following reasons:

• Submitting contracted fees may restrict a dentist’s ability to receive future fee increases. Dental carriers analyze the fees submitted on dental claims to determine if and when they will raise fees. Some track each dentist’s individual fee data to determine if that dentist is eligible for a fee increase (a.k.a. fee profiling). Others track the fee data for a specific geographic region and use that information to determine allowable fee increases for dentists in that area. For example, Delta Dental of California advises providers to report their full fees on claims because Delta Dental of California calculates future allowances using the fees submitted on Delta Dental claims by that region’s participating dentists. If participating dentists only submit their contracted fees, Delta Dental of California’s fee data will not support the need for a fee increase. In fact, given the fact that some Delta Dental plans set fees between the 70-80th percentile, dentists could actually see a fee reduction if a substantial number of participating providers submit contracted fees on claims. 
• Submitting full fees on claims also ensures that providers will receive the latest PPO fee increase approved by the carrier. When practices report contracted fees on dental claims, they may not be aware of fee increases already approved by the carrier because dental plans typically pay the lower of the fee reported on the claim form or the contracted fee. 
• Submitting their full fees on all dental claims also allows dentists to measure and analyze the effects of discounts offered by their practice, whether due to write-offs associated with participating provider contracts or patient incentives.