What can I do if a patient refuses to pay for what insurance won't cover ?

Although patients are, in many cases, responsible for paying whatever portion of the bill is not covered by insurance, this isn't always the case. In addition to certain patient co-insurance responsibilities such as deductible amounts and copayments, dental plans usually allow providers to balance bill patients for the unpaid charges (usually up to a discounted allowable fee) for more costly treatments and procedures.

When you sign a contract to participate in a dental plan's network of providers, you accept discounted fees in exchange for the plan sending you enrollees. In most insurance plans, these discounted allowances are typically deemed the maximum that you can charge for care provided to a patient in that plan. Even though you may have higher usual, customary and reasonable (UCR) fees than a dental plan allows as reimbursement for various procedures, when you are involved in any form of managed care network (be it a PPO or an HMO), you will typically not receive your full UCR fees. It is important to know the rules of all insurance plans you contract with and the fees the plans allow you to collect. Allowable fees may be less than you would ordinarily charge for care, but they represent the maximum of what you will be paid.

When there is an unpaid balance on a bill that the dental benefits carrier recognizes as the patient's responsibility, there are only two options: referring the patient and the unpaid balance to a collection agency or going to court. The court route may prove to be effective, but it typically requires hiring an attorney and introduction of evidence that supports the claim for payment by the patient. There is a risk involved in either bringing a lawsuit or sending the outstanding bill to a collections agency, in that the patient will likely evaluate all potential defenses, including a claim that the treatment rendered was negligently performed. Both the legal and the collection processes take considerable time and energy on your part to obtain the unpaid balance.