Maintaining competitive pricing while turning a profit can be a delicate balancing act for a dentist. One way to boost your income is to become an in-network provider and start billing patients per the insurer’s dental fee schedule.
Fee schedule prices may be lower than what you would charge otherwise. However, working with insurers can increase your exposure and expand your client base, with the increased turnover making up for the lower fees. This is more true now than ever before, as a recent bill could offer Medicare recipients extended coverage for dental procedures considered medically necessary.
Here is everything you need to know about dental fee schedules, and if you are interested in improving your practice’s ability to manage dental insurance, see how Weave can simplify insurance verification.
What Is a Dental Fee Schedule?
A dental fee schedule is a list of prices for specific treatments and services that insurers pay dentists, other providers, and suppliers. Insurers calculate schedule fees at their in-network rates. These set the maximum allowable fee you can bill a patient for covered services and the maximum payable by their plan.
Patient-facing fee schedules also include how much you charge for a service, such as crown installation or wisdom tooth surgical removal, and what the patient’s dental plan will cover. These amounts aren’t always the same: The insurer may have set a lower fee than your actual charge.
These calculations can be confusing for patients, so it’s crucial to explain how their health plan and your pricing combine to arrive at the overall cost of care.
How Do Insurers Calculate Fee Schedules?
Most insurers use the so-called Usual, Customary, and Reasonable (UCR) fees to determine their rates. UCR fees are standardized prices non-insured patients would pay for dental procedures in your area.
Insurers consider the following variables when setting UCR fees for services and treatments:
- Materials used
- Laboratory expenses
- Required number of appointments
- The treatment category the procedure falls into
- The cost of living in your region
- The average prices for dental services in the area
You could charge above the UCR fee for a given procedure — a tooth filling, for example — but you may not go higher than the maximum allowable fee.
How Do Fee Schedules Affect Dental Practices?
Once you sign your in-network contract and become a participating provider, you must charge insured patients according to the insurer’s dental fee schedule.
Often, fee schedule prices will be lower than your standard fees, but keep in mind that doesn’t automatically translate into lower profits. On the contrary, they can attract more patients to your dental practice. Insurers often promote participating dentist offices to their policyholders. Plus, you can continue to bill non-insured patients your regular UCR fee.
Fee Schedules and the Importance of Correct Dental Code Reporting
To reimburse you, your provider needs more than your submitted fees. You’ll also have to report a CDT dental code for each procedure. Getting this step right is paramount — here’s why:
Fee schedules set the prices for covered dental procedures based on the treatment categories they fall under. Coverage for some categories, such as crown installations, could be just 50%, while for others, it may reach 80% or even 100%. If the fee schedule allows for a maximum charge of $1,000, patients may pay anywhere between $0 and $500 out of pocket, depending on the treatment category.
Most insurers classify dental treatment into three categories:
- Diagnostic: Diagnostic procedures include assessments and evaluations such as oral exams, X-rays, and 3D imaging. Most are fully covered, but insurers have a limitation on the number of times patients can use them, usually once every 1-5 years.
- Preventive: These include prophylactic services that help prevent future issues, such as cleanings, fluoride treatments, and sealant application. Dental benefit plans usually cover prevention in full and allow one or two procedures per year. Some carriers now also cover certain COVID-19 infection control costs.
- Basic and major treatments: This broad category includes anything from minor procedures like fillings to big interventions such as final restoration after root canal treatment, crown and tooth implants, and oral surgery. Dental insurance covers these in part only (usually, 80% for basic and 50% for major treatments). Your fee schedule will show the maximum reimbursement you can claim. Some services will require prior authorization.
As you can probably tell, coverage amounts decrease as dental problems get worse. The idea is to encourage plan members to seek regular preventive and diagnostic care and address issues early.
ICD-10 and CDT Codes
Because treatment categories determine reimbursement levels, it’s critical that you enter the right CDT and ICD-10 dental codes in patients’ records and when submitting claims to insurers. This helps ensure accuracy and timely compensation.
The American Dental Association (ADA) has published a table with commonly reported CDT Codes with examples of possible ICD-10 diagnostic codes. The list is far from exhaustive, and a complex treatment plan may require multiple diagnoses and more than one procedure code. Still, this resource can provide guidance on commonly occurring conditions, so you may wish to review these ADA codes often.
Why You Should Update Your Fee Schedules Regularly
Maintaining up-to-date fee schedules should be a priority in your practice. Providing patients with accurate pricing promotes transparency and trust and helps improve retention.
Most people want to know upfront how much they need to pay you and how much their insurance plan will cover. If you estimate incorrectly because you haven’t updated your fee schedule, you risk under-collecting. Alternatively, you’d have to send a follow-up bill to collect the remainder, which could hurt your brand and undermine trust.
Additionally, staying up-to-date with fee schedules can even attract new customers to your practice. On Feb 6, 2023, Rep. Steve Cohen introduced the Medicare Medically Necessary Dental Care Act; a bill that could expand coverage for Medicare beneficiaries on dental treatments and procedures considered medically necessary. Understanding these types of changes and adjusting your practice’s fee schedules to accommodate new Medicare coverage could set your dental office apart from others in your area.
Another reason to keep fee schedules up-to-date is to eliminate the need for adjustments in your dental practice software. Fewer adjustments make for cleaner ledgers and statements, fewer mistakes, and faster payment processing.
Simplify and Streamline Dental Payments Using Weave
Weave Payments is our all-in-one payment processing solution for dental offices, mental and behavioral health practices, and medical services.
The platform packs in multiple options for contactless payment, enabling you to collect outstanding balances from patients. You’ll also benefit from simplified billing workflows, smoother communication, and best-in-class security and privacy practices — so you can spend less time worrying about your dental fee schedule and more time taking care of patients.
Get a demo to see Weave Payments in action, discover our broader suite of cloud-based online services, and learn how we can transform your practice.
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