We are asked on occasion if we can waive the deductible or co-payment that a patient needs to pay and the answer is “no.” It is against the law for a dental office not to collect the deductible or co-payment. Not only is it insurance fraud, but it is against the regulations of the Royal College of Dental Surgeons of Ontario (RCDSO) that regulates dentists. This practice is considered to be professional misconduct and a dentist can lose his/her license and receive a fine.
As a dental office we are here to provide the services and information on available treatment options appropriate to address your dental needs regardless of the nature and extent of your dental coverage and we can also assist you in receiving the benefits that you are entitled to under your dental plan.
It is very important to understand your dental plan as it is a valuable benefit. Many employers provide benefits, in addition to salaries, as a method of paying their employees. In order to be able to offer dental plans to their employees, companies design the benefit package so that the employee shares in the cost of their dental care. Below is information on frequently asked questions with respect to insurance plans, deductibles, co-payment and co-insurance as answered by the Ontario Dental Association.
What plan limitations are employers using to involve the employee in dental care costs?
Some of the most common benefit plan designs currently being offered are:
(1) Annual Deductible Amounts – In this case, the employee may be required to pay the first $25 or $50 claimed every year.
(2) Frequency limitations – Dental plans may limit the number of visits to the dentist each year that will be covered by the insurance plan
(3) Annual Dollar Maximums Employers may create a maximum limit (e.g., $1,500) that the dental plan will cover each year.
(4) Co-Payment (or co-insurance) Through a sharing formula specified in the dental plan contract, the dental plan may only cover a percentage of the eligible amount claimed. The employee is responsible for paying the remainder.
When are co-payments used?
Co-payments are sometimes applied to diagnostic, preventative and basic services, but they are more frequently applied to comprehensive or extensive services such as endodontics, periodontics, prosthodontics and orthodontics. Sometimes your plan will cover 80 percent of the bill leaving you to pay the other 20 percent (an 80 – 20 co-pay), other times, it could be on a 50 – 50 basis, or even other amounts. It all depends on the plan.
How do co-payments work?
Here’s how it works: Your dentist bills you for $100 for your dental treatment. Before the claim form goes to your insurance company, you sign the claim form, verifying that the charge is accurate and that you are financially responsible to the dentist for the entire charge. This is an important step because your dental plan may not cover the whole bill. For example, if your plan pays 80 percent of an eligible expense of $100, your insurance company will cover the first $80 leaving you responsible for paying the remaining $20 as an out- of-pocket expense.
Do I have to pay the co-payment?
Yes. It is against the law (insurance fraud) for you or your dentist to conspire to avoid paying the co-payment. Not only is it a violation of the law, but it is contrary to the regulations of the Royal College of Dental Surgeons of Ontario (RCDSO
) that regulates the dental profession. This practice is considered professional misconduct and a dentist can lose his license for it, as well as incurring hefty fines, often exceeding $10,000.
By law, a claim made to an insurance company must be an accurate description of services rendered and fees charged. This is why you are required to sign the claim form before it is submitted to your insurance company.
How would an insurance company know that I did not pay my share?
Insurance companies reserve the right to request that the patient provide proof that the co-payment has actually been paid. If the patient is unable to provide that proof, the insurance company may demand that the patient make financial restitution to the insurance company or it may apply the over-payment to future claims payments.
What if my dentist gives me a discount on certain fees?
Your dentist may do this but this is very different from waiving a co-payment. If your dentist discounts his/her fee to you by a certain percentage, then that discounted fee must be the fee submitted to your insurance company as the whole fee charged for the services rendered.
Your dental plan is a valuable benefit. Before you ask your dentist to waive a co-payment, think about the consequences to you and your dentist.
For more information on your dental benefits be sure to contact your insurance company or call our office and we can assist you in understanding your benefits.
Dr. Elizabeth Dimovski Dental Office