Dental clinics in insurance networks must have reduced prices for some of their procedures due to their contract with the insurer. They may have to apply them to noncovered services, depending on their state and the insurance company they contracted with. Consequently, dentists could choose to either not offer certain procedures due to cost constraints or not accept certain insurance plans. They could negotiate these fees with the insurance companies, but the increased fees may not be substantial enough to increase overall revenue. They can offer procedures at the full fee when they are not listed on the PPO fee schedule.
State Laws & Noncovered Services
In most states, laws do not allow insurance companies to reduce prices for noncovered services. These state laws apply to noncovered services, but not services affected by provisions in their contract. States, such as California, Arkansas, and Connecticut, have those laws, benefiting dental practices, which could offer noncovered procedures at their full price. However, these laws also mean that patients would not pay reduced fees for these noncovered procedures. The laws also distinguish noncovered services from services limited by provisions in their contract.
For instance, in California, the law does not apply to covered procedures and services that have, according to the CDA, “‘contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, or alternative benefit payment.” Similarly, Arkansas’ law also excludes covered services that are “reimbursable subject to a deductible, waiting period, frequency limitation, annual or lifetime maximum, or other contractual limitation from their noncovered services classification.” Meaning, dentists still have reduced fees for covered procedures with contractual limitations in accordance with their contract with the insurance company.
Some of these state laws may not apply to self-funded plans. This type of dental plan can come from large employers, such as government employers, unions, and other businesses, that have operations in more than one state and are typically administered by commercial dental plans. Self-funded health plans are not regulated by state law, but rather by federal law. Consequently, depending on their state, such as California, dental clinics contracted with self-funded dental plans must agree to any reduced fees for their non-covered procedures.
Dental practices should be aware of any noncovered services law in their state because they could charge full price for these procedures in order to earn more revenue. However, some states may not have such laws and these laws may not apply to every dental plan.
If you are struggling with the ins and outs of various dental plans, consider partnering with eAssist. Our Success Consultants are knowledgeable about the many different coverages available and will ensure your claim is billed correctly. To learn more, schedule a consultation here.
