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.

Dentist Problems In Billing Forms With Patients

Common questions & answers with patients insurance collections and dental benefits plans.

What can I do if a patient refuses to pay for what insurance won't cover ?
When the parents are divorced, who should pay for a child's treatment ?
Is it reasonable to check my patient's credit history before I start treatment ?
Can I charge interest for late payments ? If I do so, am I required to notify patients before I start charging interest ?
What notices am I legally required to provide patients to whom I offer third-party financing ?
What if the patient doesn't return for completion of the treatment and the dental plan has already paid for it ?
Can I offer a discount to my patients who pay in full prior to treatment ?
Are there legal problems in giving discounts to family, staff or colleagues ?
If a patient is behind on payments, can I withhold records or stop treatment ?
How do I collect an unpaid balance if the patient is in bankruptcy ?
A patient is owed a refund from overpayment, but I cannot locate the patient to send the refund. What do I do with the funds ?
What do I need to know about working with a collection agency ?
What are the federal and state laws that apply to my collection efforts ?
Is there a statute of limitations for collecting debt ?
Is small claims court an option for collecting unpaid bills ?
What should I do if a patient isn’t satisfied with the quality of treatment and wants a refund ?
Should I use the fee allowed by the plan for each procedure or my own usual, customary and reasonable (UCR) fee ?
Can I waive patient copays ?
Can I establish a discount program in my practice for patients, and what are the legal requirements ?
How soon must I submit a claim in order for it to be considered valid ?
How soon must a dental plan or insurer pay submitted claims ?
What options do I have if I disagree with the insurance plan's payment decision ?
A dental plan is auditing my practice - what does this mean ?
Does an auditor have the authority to access patient records ?
How can a dental office prepare for an announced audit ?
What if the office fails the dental audit?
Are plans required to pay for in-hospital dental treatment ?
Does obtaining a prior authorization from a patient's plan obligate the plan to pay for that treatment ?
Can lab costs be charged on a claim separately from a procedure ?
Must refund demands from dental plans always be paid ?
What should I be aware of when considering contracting with a plan to join its provider network ?
Can I balance bill a Denti-Cal beneficiary for the portion of my bill that wasn't paid by Denti-Cal ?
May I charge a Denti-Cal patient for an alternative procedure that is not a covered benefit of Denti-Cal ?
Must an associate dentist in my office be separately enrolled as a Denti-Cal provider if I am enrolled as a provider ?
What is the best way to obtain information about the treatment, provider participation and payment policies of the Denti-Cal program ?
How and when your practice verifies patient insurance coverage ?
What medical plans will pay for in dental operations ?

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