First, I’d like to thank Dr. Shaffer for her interest in this column. I agree that it can be argued that the patient who pays in full at the time of service does not place additional billing or claim form burdens on the administrative staff. (These patients often do request a year-end statement for preparation of their personal income taxes, however.)
With computerization of many dental offices, neither of these functions is excessively burdensome, in my opinion. Yet, I also understand that some practices may give a percentage discount for any patients who pay in full at the time of service.
This does not appear to be unreasonable, and I believe that it may be commonplace in many parts of the country. In fact, some suggest it may be a good business practice as it does not result in accounts receivable, which we all realize decrease in value over the time they remain uncollected.
Second, our professional fee schedules are based on the fees we charge our patients for a standardized procedure. Well, I know that one of the first things I figured out in dental school was that there was no truly standardized procedure. A mesio-occlusodistal (MOD) composite on tooth no. 29 is not going to require the same level of skill and time as a MOD composite on tooth no. 32, and yet the procedure code is the same: D2393, "Resin-Based Composite —Three Surfaces, Posterior."1
We create our fee schedule somewhere in between what it actually should be for these two extremes. Is it fair to charge the same fee for tooth no. 29 as tooth no. 32, even if it takes a lot less time, skill and effort for one versus the other? If we wanted to be most equitable, we would charge our patients by the hour regardless of the procedure. In fact, some practice management consultants suggest that dentists base their fee schedule working backwards from how long it takes to complete a procedure, based on an hourly production goal. My examination fee doesn’t pass muster in these circumstances.
Third, accepting anything less than your designated fee schedule is largely a business decision. However, accepting government-sponsored, third-party programs to treat the underserved is, in my view, a professional and, yes, even an ethical decision (see Advisory Opinion 5.B.3, "Fee Differential"2).
To me, treating the under-served in some way, at some level, is a basic responsibility of the professional in exchange for being allowed to practice dentistry. I consider it a duty or responsibility of being considered a member of our chosen profession (see Principle 3.A, "Community Service" 2). Most of my patients understand and, I would say, some even expect that I offer some reduced fee care or free care to some of the less fortunate and underserved in my community.
Fourth, by accepting fees based on third parties’ reimbursement allowances, you are in effect discounting your usual fees, not creating a new fee schedule. However, waiving the insurance co-payment without disclosure has been determined to be unethical, as it misrepresents the actual fee you charge and intend to collect. It may also raise potential insurance fraud concerns, as co-payments are put in place to moderate utilization by having patients share in payment for their dental care (see Advisory Opinion 5.B.1. "Waiver of Copayment"2).
Yes, it is simpler to collect 100 percent of the fee in your fee schedule for each procedure delivered. That would be the ideal business model. In my opinion, we operate a professional practice, delivering professional services in a business world. We must turn a profit so that we can keep our offices open. Otherwise we all lose.
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