what is non assignment dental office

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Insurance Tips – Assignment Vs. Non-Assignment

March 13, 2023

Insurance Tips – Assignment Vs. Non-Assignment Author: Dr. Aisling Whitaker […]

Author: Dr. Aisling Whitaker

In our series of dental reception basics, we will explain some of the most common topics that you need to know. In Canadian insurance, there are two options of how you can bill and collect the patient’s fees.

In either case, you can send the codes to the patient’s insurance digitally or via mail. The difference lies in who the insurance pays out.

Also known as direct billing, assignment means that the insurance will pay the clinic directly. Here the patient will pay the clinic the amount that is not covered by their insurance policy, the co-payment.

For example, Nadia has 80% coverage for her treatment. The total cost is $100. The insurance will pay the clinic $80, so you will collect a $20 co-payment from the patient on the day of treatment.

Non Assignment

Non assignment means that the insurance will pay the patient directly. Here the patient will pay the clinic the full amount and they will receive the re-imbursement from their insurance.

For example, Nadia has 80% coverage for her treatment. The total cost is $100. She pays the clinic $100 and the insurance will re-imburse her $80.

Submitting the claims

When sending an eclaim or paper claim, you must confirm that you have chose the correct setting (assignment or non-assignment) prior to sending. Some insurance policies do not allow for assignment, so always read the resulting report to confirm who the insurance will pay to.

The content of this article is provided for general information purposes only. It is not intended to provide medical or other professional advice, or opinions of any kind and may not be used for professional or commercial purposes. No one should act, or refrain from acting, based solely upon the content of this article, any links provided in this article, or other general information without first seeking appropriate professional advice. Nothing in this article should be understood to create any fiduciary or professional service relationship .

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Moving Your Practice to Non-Assignment is Easier Than You Think

In the dental profession, it is generally understood that dental benefits are merely a subsidy intended to defray the costs of treatment. Yet the terms and parameters of a benefits plan can have a strong influence on a patient’s treatment decisions. How often do you hear the question, “Is this going to be covered by my insurance?” Dental teams struggle trying to convince patients of the need for treatment when it is not covered under a benefits plan.

To provide the best possible care for your patients, your practice should aim to be patient-centered, not insurance-driven. If your office is too reliant dental insurance benefits, you could be putting your practice at risk. After all, it is the employers who select the insurance plan and level of benefits.  In times of economic stress, employers must look at cutting costs in order to survive. The first place they look is at their expensive benefits programs.  Dental insurance benefits are a costly component of group benefits packages and when companies experience economic downturns, they are often the first to be eliminated.

In choosing to accept assignment, you also create the perception that your office is acting as a benefits plan administrator. If the level of coverage suddenly changes at the employer level or if benefits are denied for a specific service, the patient might blame your office if they believe you control their benefits level.

One way to guard against these scenarios is to change your office from assignment to non-assignment. Change is challenging, so it is best done slowly and strategically with built in flexibility to accommodate all of your patients’ needs. Here is a 3-step plan to help guide you through the transition.

1. Establish flexible financial options and policies in your office. Focus on what you can offer patients by emphasizing the opportunities not the constraints. For instance, monthly payment plans at 0% interest for larger cases are often attractive to patients. Such interest-free financing is an excellent marketing tool and can make certain treatment plans more accessible and affordable.

Another way to accommodate your patient’s needs is by accepting monthly payments through pre-authorized credit card payments or direct debits.

2. Set a target date that is one year to 18 months in the future and start talking to your existing patients about the various financial options available. Place a sign at the front desk announcing the pending changes and the effective date. If you send account statements to existing patients, include an information insert with details of the changes.

When your patients come in for their regular appointments, talk to them about why you are making the changes and how they will affect them. During the new patient interview, discuss the financial options available and emphasize how easy it is for patients to receive the care they need. Reinforce the idea that dental benefits are a contract between the patient and their employer and that treatment recommendations are strictly part of the dentist-patient relationship. These strategies will allow your patients adequate time to adjust to the new payment policies.

3. Educate and inform your dental team. The entire dental team needs to believe in and support your new policies. For instance, members of staff should avoid prejudging a patient’s willingness or ability to pay for treatment. Such preconceptions generally have a negative effect on the outcome. You should discuss the new realities of becoming a non-assignment office with members of your staff well in advance of making the change. Address any preconceptions or concerns staff may have about the new policies.

Some dentists are concerned that patients may leave their practice if they become a non-assignment practice. Patients are adaptable as long as they are well informed and presented with alternatives. The strength of your relationship with patients will help them remain loyal. Help your patients become informed consumers and to make dentistry a priority in their purchasing decisions.

Moving your practice from assignment to non-assignment may appear to be daunting, but the benefits far outweigh the risks. You will protect your practice against the threat of financial loss during economic downturns while providing client-specific health care. The key is educating your patients and dental team while displaying flexibility and offering excellent customer service. Your patients will continue to be happy, willing to refer their friends and relatives, while you can enjoy a practice that has improved cash flow and fewer financial concerns.

If you wish to offer assignment as another option for your patients, feel free to contact me at [email protected] with the words “assignment policy” in the subject line and I will be happy to send you a sample policy that you may implement in your office. 

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Exploring the Path Less Taken: Should You Switch to Non-Assignment?

Should you Switch to Non-Assignment?

Deciding to switch from a traditional dental practice to a non-assignment clinic takes work. We understand the complexities, challenges, and considerations that come with such a significant shift in the practice model. It entails reevaluating established norms, questioning the status quo, and venturing into uncharted territory.

We recognize that managing the delicate balance between providing exceptional dental care and navigating the complexities of insurance reimbursement is a constant challenge.

Our goal is not to advocate for or against a specific practice model but to empower dentists with knowledge and resources to make informed decisions. We understand the weight of this choice and the potential impact it can have on the dentist's professional and personal life.

In addition to understanding the difficult decision to switch to a non-assignment dental clinic, it is crucial to acknowledge the common pitfalls that often motivate dentists to consider this transition. These pitfalls, such as the ones listed below, encompass the challenges and frustrations experienced within the traditional insurance-driven model. Below are common pitfalls that push practice owners toward making the switch.

Insurance Claim Denials and Delays: Dealing with insurance claim denials or delays is a common challenge that dental practices face. Whether due to incomplete documentation, coding errors, or policy limitations, denied or delayed claims can significantly impact cash flow and leave accounts receivable unresolved.

Patient Misunderstanding of Insurance Coverage: Patients often need help to fully understand their insurance coverage, leading to confusion regarding their financial responsibilities. This lack of awareness can result in delayed or partial payments, leaving dental practices with outstanding balances that are difficult to collect.

High Deductibles and Co-Payments: Rising deductibles and co-payments have become a common trend in dental insurance plans. Patients may need help covering these out-of-pocket expenses, leading to delayed or partial payments. This can have a ripple effect on accounts receivable, as practices may have to wait longer for the full payment.

Financial Hardships and Unforeseen Circumstances: Life can be unpredictable, and patients may face unexpected financial hardships or unforeseen circumstances that impact their ability to pay promptly. Job loss, medical emergencies, or other personal crises can hinder accounts receivable, making it difficult for dental practices to collect the full payment within the desired timeframe.

Ineffective Communication and Follow-up: Poor communication and inadequate follow-up processes can contribute to unresolved accounts receivable. Suppose dental practices fail to send timely and transparent invoices, reminders, or follow-ups on overdue payments. In that case, it can lead to a breakdown in communication and prolong the collection process.

Lack of Efficient Payment Systems: Limited and outdated payment options can create barriers to timely payments. If patients cannot conveniently make payments through preferred methods such as online platforms or electronic funds transfer, it can result in delayed or missed payments, further hindering accounts receivable management.

Inadequate Staff Training and Resources: Insufficient training of staff members responsible for managing accounts receivable can impede practical collection efforts. If the staff needs proper knowledge about insurance processes, billing procedures, or techniques for handling patient inquiries, it can lead to errors, delays, or missed opportunities for collecting outstanding balances.

It's no wonder some practice owners move their practice to non-assignment. If this option is in your sights, review the following considerations:

Administrative Burden and Processing Time: Accepting assignment means the dental practice submits insurance claims on behalf of patients and receives direct reimbursement from the insurance provider. This can save patients the hassle of dealing with claims paperwork, but it places the administrative burden on the practice. Becoming a non-assignment provider shifts the responsibility of following up on claims submission and reimbursement to the policy holder, reducing the administrative workload for the practice. However, offering to submit claims by mail or electronically on their behalf is still expected.

Patient Responsibility and Cash Flow: By becoming a non-assignment provider, patients become responsible for paying the practice directly and seeking reimbursement from their insurance provider. This could lead to delays in payment from their insurace provider and require patients to have sufficient funds upfront to cover the cost when services are rendered. It's essential to assess the demographics of your patient base and their ability to manage out-of-pocket expenses before making this decision. A potential downside of non-assignment is the risk of increased accounts receivable if patients struggle with prompt payment.

Patient Satisfaction and Retention : Consider how becoming a non-assignment provider may impact patient satisfaction and retention rates. Some patients prefer the convenience of having the practice handle insurance claims directly, as it simplifies their payment process. Others may appreciate the extra points from using their credit card. It's crucial to communicate the change clearly to patients, emphasizing the benefits and addressing any concerns. Transparency information and exceptional customer service can help maintain patient satisfaction and retention.

Financial Analysis and Risk Assessment: Conduct a thorough financial analysis to assess the risks and benefits of becoming a non-assignment provider. Consider the impact on cash flow, profitability, and the ability to collect patient payments. Evaluate the costs and resources required for managing the administrative aspects of non-assignment, such as generating invoices and providing necessary documentation for patient reimbursement.

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• Making a Dental Benefits Claim

Key Takeaways

• The way you submit a claim depends on the type of plan you have.
• The assignment of benefit plans is seen as more convenient.
• The ODA believes non-assignment of benefits is best, as it makes you become a more active participant in your coverage.

Your Plan and the Claims Submission Process

Once your dental appointment is over, it’s time to make your payment and submit your claim. The way you submit your claim and get reimbursed depends on:

• whether the dentist submits it for you;
• whether you assign your benefits to the dentist; 
• or have the plan pay you directly.

Some dentists accept the assignment of benefits . The assignment of benefits means your insurer pays your dentist directly. The dental claim can be submitted to the insurance company by the dental office. All you need to do is provide the dental office staff with your benefit plan number and/or benefits card. Any fees that are not covered by your plan must be paid by you to the dentist.

There are some dentists who do not accept the assignment of benefits; there are some dental plans that will not allow benefits to be assigned. This means that the plan member (you) will be paid by the insurance company. In both cases, this means you’ll need to pay your dental bill upfront. The dental office can still submit the claim electronically to your insurance provider on your behalf and then you wait to get reimbursed.

Getting reimbursed is much faster than it was years ago. Thanks to electronic claims submission, you can see the dentist on Monday and usually get reimbursement before the end of the week. Also, many dentists accept credit cards, which typically have a monthly billing cycle. If you need complex treatment, speak to your dentist about arranging a payment schedule that allows you to budget for expenses.

Benefits of Non-Assignment 

The main benefit of the assignment of benefits is the convenient payment process for patients. However, the ODA opposes the assignment of benefits; instead, we believe that non-assignment of benefits is best .

Why does the ODA oppose something most patients find convenient? Because non-assignment means that patients are more involved in their care and the costs involved.  

By being more involved you can:

• Have a better understanding of your dental plan and can use it wisely.
• Evaluate your dental plan and identify parts that could be improved.
• Develop the confidence to discuss fees with your dentist.

Most dental offices can submit your claim for you electronically as a courtesy. If you need to submit your own dental claim form and need help, your human resources department or your dental plan administrator can assist you.

Determining Dental Fees

How are dental fees calculated? How do dentists determine the cost of treatment?

Learn more about dental costs

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What is non assignment & assignment?

Does every insurance company do direct billing, my insurance company doesn’t accept assignment or edi, now what, all dental services provided by our general dentists.

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• Beachstone Dental | Your Dentist in Leamington, ON
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The Beachstone Policies

Patient Information and our Office Policies.

We thank you for choosing Beachstone Dental for your oral healthcare needs. Our mission is to provide you and your family with the highest level of dental care available today – delivered by our experienced and gentle dentist in a friendly and relaxing spa-like environment.

When you walk through our doors, you’ll be met with a welcoming smile and a calming space. Beyond our patient lounge, you will be given a quick tour of our state-of-the-art clinical area, and then seated in our premium dental chair in our fully-equipped treatment room. At the end of your exam, you will be taken to our private consultation room to discuss any treatment options (if needed). Your comfort, safety, and convenience will always always be our top priority.

Your initial visit with us will be focused on getting to know you and your needs. Dr. Prasad will complete a comprehensive oral exam and talk to you about your dental care needs and goals. We want your smile to shine brightly and for your teeth to be strong and healthy enough to last you a lifetime.

Below are some of our office policies and patient information. If you have any further questions, please don’t hesitate to contact our office – we’re always happy to answer any questions you may have.

For more on what you can expect as a new patient of our practice, please visit the Beachstone Experience . When you are ready to schedule your first visit with us and become a Beachstone Patient , please get in touch with us to get started!

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[email protected], contact us », medical and dental health information.

Part of getting to know you and providing safe, personalized dental care involves reviewing your medical history. We ask all patients to complete mandatory health forms during their first visit so that we can prepare your experience and offer expertise tailored to your needs.

When booking your appointment or completing your forms, please advise us of any relevant health conditions you may have.

Please alert the office if you have a medical condition that may be of concern prior to treatment (i.e. diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever, joint replacement, etc.) and/or if you require medication prior to dental cleanings (i.e. antibiotics for pre-med.).

Certain medical conditions and medications can influence your treatment protocols – so you will be asked to provide a list of your medications. It is crucial for us to know what medications you are taking and what dosage. This includes over the counter medication and natural health products.

Please note that due to the ongoing novel Coronavirus (COVID-19) pandemic, we will be asking you some questions to prescreen you over the phone prior to your visit. We will also require you to fill out a COVID-19 Screening and Treatment Consent form and receive a temperature check when you arrive for your appointment.

To help us assess the overall health of your smile: full-mouth x-rays and a comprehensive exam of your teeth, gums, mouth, and jaws, will be performed, including a non-invasive oral cancer screening during your first visit with us.

If you have visited another dentist in the recent past, you should consider contacting your previous dentist to see if there are current x-rays that could be forwarded to our office. If you prefer, please let us know and we can send you a form to fill out and do it on your behalf.

Please remember that your dental health is affected by your general medical health and it is important for you to notify us if any information changes so we can update your records.

Financial Policy

Beachstone Dental fees for dental services are based on the ODA Fee Guide, as set by the Ontario Dental Association.

Each patient is unique and requires treatment based on their particular oral healthcare needs and goals. Therefore, Dr. Prasad will review your medical and dental history, take x-rays, and complete a comprehensive oral examination before establishing your treatment planning and the fee for care. Our dentist will share his findings with you and answer any questions and/or concerns you may have. He will explain to you the recommended treatment (if necessary), the estimated costs involved, and the payment options. If you choose to proceed with the recommended treatment, he will set a date for your follow-up appointment(s) and guide you back to the reception area so our friendly team can take care of the billing.

Please remember that as a patient, it is your responsibility to pay the fees for your dental procedures. Full payment for services is due at the time services are rendered unless prior arrangements have been made. Please bring your payment information with you to your dental appointment. We offer flexible payment options, and we accept cash and most major debit and credit cards. We suggest you use a rewards card so you can collect free reward points (i.e. cashback, travel points, etc.) on your card.

You play an important role in your dental care, and we believe all treatment and dental care decisions should be a collaboration between you and your dental care provider. You will never have surprises when it comes to your bill and the choice to proceed with treatment is always yours.

We want to help you receive the dental care you deserve. Your smile is as important to us as it is to you.

Insurance and Billing Information

If you have dental insurance , a dental plan can be a great help in covering the cost of dental care. Our office accepts most major dental insurances and we will file most claims online on your behalf as a courtesy to you. Please bring all medical and dental benefit information and cards to your visit.

Please note that Beachstone Dental is a non-assignment office, as recommended by the Ontario Dental Association , and we do not accept assignment payments from insurance companies. This means that you will pay us first for your treatment at the end of your appointment, we will directly submit your dental claims online on your behalf, and you will receive the reimbursed payment from your insurance deposited directly into your own account or by check.

Why the ODA Opposes Assignment The ODA is opposed to assignment of benefits and actively encourages dental plan sponsors to make their dental plans “non-assignment” plans. Many people wonder why the ODA would oppose a process that many find convenient. The answer lies in the fact that “non-assignment” dental plans can be less expensive than those that allow assignment, simply because the act of a patient paying for their dental care makes them financially involved in their oral health care. This provides very a good incentive for the patient to use their dental plan wisely. Dental claim reimbursement is much faster than it was years ago, and patients are finding that when they pay the dentist directly their reimbursement cheque is received quickly; greatly minimizing the time they are out of pocket. It is not unusual to see the dentist on Monday and have the reimbursement cheque before the end of the week, thanks to electronic claims submission. Also, many dentists accept credit cards, which typically have a monthly billing cycle. If complex treatment is necessary, dentists can arrange a payment schedule that allows a patient to budget for expenses and get reimbursement that is more conveniently timed. Active decision-making about oral health care by patients and meaningful involvement in the financial matters of dental care, including the dental plan, is an important part of achieving excellent oral health care.

Beachstone Dental is happy to submit, process, and complete any necessary forms or estimates to your dental insurance company at your request. We can assist you in obtaining benefit information and help with claim submissions and per-authorizations as a courtesy to you; however, it is the patient’s responsibility to know what is covered in their plan, including any limits to the plan or changes, and to seek reimbursement from their dental plan provider.  We want you to remain in control and fully aware of your treatment costs and dental benefits at all times.

The Ontario Dental Association , explains the benefits of the process below.

This simple process has far-reaching benefits. The patient is aware of the cost of the dental service and will be more likely to: comply with treatment regimens; acquire knowledge about the nature and extent of dental benefits; become a better consumer of dental care and wise user of dental benefits; develop an important comfort level for discussing fees with the dentist; identify areas in the design of a dental plan that could be improved and apprise dental plan sponsors in response. The ODA has a long-standing philosophy encouraging non-assignment dental plans for the simple reason that when patients have a meaningful financial involvement in their dental care, better decisions are made.

We agree with the ODA and we believe an informed patient will utilize their dental benefits to maximize their overall health. As your dentist, we are happy to work with your insurance provider to ensure you get the best coverage available to you.

We recommend that you contact our office prior to your appointment to provide us with your insurance information if you would like verification of benefits. Upon request, we will submit a claim to predetermine your insurance benefits; however, this is usually not required by most plans. We will provide you with a written estimate for all recommended dental treatment. We can offer you explanations of your dental benefits and financial responsibilities up front, and work with you to ensure financing if needed. This will include the cost of treatment, estimated insurance coverage, and estimated patient share. However, it is possible that your dental plan may not always cover the full cost of your required treatment. Therefore, it is important for you to know how your dental plan is designed, including its limitations and deductibles so that you can be prepared to pay on the day services are rendered.

Please remember we cannot guarantee any estimated coverage because the insurance policy is an agreement between you, your employer, and your insurance company.  The details of a patient’s insurance plan are protected by the Personal Information Protection Act (PIPA). Due to these privacy regulations, it is sometimes difficult for us to communicate with insurance companies regarding payments. It is your responsibility to know what your insurance covers and to inform our office of any changes to your insurance (i.e. carrier, policy, identification numbers, or plan maximums). This will ensure that your claims are processed correctly.

Ultimately, you are directly responsible for all charges incurred at Beachstone Dental regardless of your insurance company’s coverage. If you need assistance or have questions about your insurance policies or claims, please do not hesitate to call our office – our staff is always available to help you!

Privacy Policy

At Beachstone Dental, we value your privacy and will not share your information with other parties without your consent. For more information, please read our Privacy Policy and Terms of Use . You will also be given a copy of our office policies, including our privacy policy, to review and sign when you visit us for the first time.

Important Requests

A parent or guardian must accompany all patients under 18 years of age. If you have any questions, please don’t hesitate to contact us. We are here to help you.

Your dental appointments are reserved specifically for you. Although we will contact you prior to a scheduled appointment with a courtesy reminder, it is ultimately your responsibility to make sure that you arrive for the appointment on time.

If you need to reschedule a reserved appointment, we ask that you give us at least 48 hours’ notice. This permits another patient to receive dental care in your absence. If you miss an appointment without giving notice, a missed appointment fee will apply.

At Beachstone Dental, we are dedicated to making your experience as pleasant, worry-free, and convenient as possible – ensuring you benefit from shorter treatment times, faster healing, and a lifelong smile.

All the information you need to know is right here on our website, so feel free to get to know our dentist, tour our facility, explore our dental services, and check out our financing options. If you have any further questions, please don’t hesitate to call our office – we’re always happy to answer any questions you may have.

Please reach out to us to get started! We look forward to welcoming you to our office!

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Assignment Of Benefits Explained

Helping patients access quality dental care.

If your dental office bills directly to your insurance carrier and does not require you to pay up front for the services your insurance covers, your dentist is providing you with a service called assignment of benefits. We are Calgary NW’s top family dental clinic, book your next appointment now!

As part of our exceptional service to our clients, we provide what’s called an assignment of benefits. This service ensures that our dental office bills directly to your insurance carrier and does not require you to pay upfront for the services your insurance covers. In a non-assignment office, patients must pay the full cost of treatment and complete a dental claim form that the patient can submit to their insurance provider for reimbursement.

The health of your teeth and gums is connected to your overall well-being. Damaged teeth and a misaligned bite can lower our confidence when interacting with others while a severe toothache can become a constraint in our day. These are just two examples of how oral health can impact our quality of life.

At Brentwood Village Dental Clinic, we recognize that the costs associated with treatment can be stressful for some families and paying the full bill upfront can be a financial constraint. We believe that dental care should be accessible for everyone, which is why we strive to make your experience as smoothas possible, including the payment and claims process.

Professional dental care is an important part of your overall health. Give us a call today to speak about your options – we are ready to answer your questions!

How it Works

Assignment services are a benefit for you.

In offices that do not provide this service, patients, regardless of their insurance status, are required to pay for their dental treatment at the time of the appointment. Patients are then left to pursue their insurance companies for reimbursement personally.

It is estimated that no more than 30% of dental offices today provide assignment services. The following is an abbreviated list of the reasons why most dentists do not provide assignment services.

• The provider ends up waiting usually weeks or months for payments to arrive from the insuring agency.
• In order to cope with the large amount of paperwork required to submit and follow up on insurance claims, offices providing assignment must staff considerably more employees than those offices that don’t provide assignment services.
• Once a payment is made to the provider, if any treatment was denied due to exclusions or limitations in the patients insurance plan, there will be a balance owing. In this circumstance the provider now has the responsibility of tracking down the patient for the rest of the payment; sometimes meeting with distrust and hostility on the part of the patient.

So in short, dental offices who provide this service are doing so as a courtesy to their patients to make dental services more accessible. They are making it possible for you to have your dental work done and not be out of pocket for the expenses. They are not required by any provincial or federal legislation to do so and yet they will wait sometimes months for payment on the patient’s behalf.

Did You Know?

It is your responsibility to provide the staff with the proper numbers and insurance information.  The limits, restrictions and deductibles on your dental plan were put there by your insuring agency, not the dental office.  The dental office has nothing to do with these limitations nor can they do anything about them. Offices that provide assignment services have the right to revoke them at any time.

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Dental Benefits 101

So you just got dental benefits through your employer, hurray! Where do we begin?

Dental Plan Basics

Some individuals purchase their own dental plan, but most have dental benefits through their employer. When your employer chooses your insurance plan, they decide the plan’s cost and how often you use their benefits. Most employers will also deduct a portion of each of your paychecks to split the cost of the insurance premiums .

Although they choose the plan, your employer is not responsible for administering your dental plan. Instead, they enter into a contract with an insurance company who then acts as your dental plan administrator. Your dental plan administrator can answer questions about your insurance coverage and must reimburse you based on the terms of the dental plan contract.  For some dental services, payment is based on a cost-sharing arrangement between you and your employer. In these cases, you pay for part of the cost, while the plan pays for the rest.

Your Responsibilities

Your dentist may not be familiar with your specific plan coverage so it’s important to know how your plan works. Always read the information booklet or other materials available from your benefits provider.

Some things you should know about your plan:

• What is covered each year?
• Is there a deductible?
• Is there a total dollar limit on my coverage?
• Can I choose a procedure other than the one my plan covers?
• Will I still be covered if I change jobs?
• How much am I covered for cleanings and X-rays?
• How much am I covered for fillings and root canals?
• What about other treatments like bridges and crowns, dentures and oral surgery?

You should also be aware of your co-payment. Co-payment — also called co-insurance — is the part of the bill you won’t be reimbursed for. Many dental plans have a percentage of the claim amount (typically 20 to 50 per cent) that is not covered by the dental plan.

Can my dentist waive my co-payment?

No — waiving a co-payment is insurance fraud and is against the law. Your dentist could be fined or even lose their license.   The claim forms you and your dentist sign state which services were provided and how much was charged. The insurance company pays its share based upon the assumption that you will do the same.

Your Dentist’s Responsibilities

Dentists make their treatment plan based on your dental needs. Sometimes, your dental plan coverage and your treatment plan won’t align. If your dental plan only covers part of the cost of your treatment plan, you’ll need to cover the rest.

Your dentist will take you through your personalized treatment plan and answer any questions you may have. They can also help you understand how much may be covered before you move ahead by submitting a pre-treatment form to your dental benefits administrator. Your benefits administrator will provide you with a “predetermination of benefits”. This doesn’t guarantee that the treatment will be covered by your health insurance plan. But it will show you what services are covered and the limitations of your plan.

Remember that your dentist is treating you, not your dental plan. Read more about your dentist’s obligations according to the Royal College of Dental Surgeons of Ontario.

Your Plan and the Claims Submission Process

Once your dental appointment is over, it’s time to make your payment and submit your claim. The way you submit your claim and get reimbursed depends on:

• whether the dentist submits it for you;
• whether you assign your benefits to the dentist;
• or have the plan pay you directly.

Some dentists accept the assignment of benefits. The assignment of benefits means your insurer pays your dentist directly. The dental claim can be submitted to the insurance company by the dental office. All you need to do is provide the dental office staff with your benefit plan number and/or benefits card. Any fees that are not covered by your plan must be paid by you to the dentist.

There are some dentists who do not accept the assignment of benefits; there are some dental plans that will not allow benefits to be assigned. This means that the plan member (you) will be paid by the insurance company. In both cases, this means you’ll need to pay your dental bill upfront. The dental office can still submit the claim electronically to your insurance provider on your behalf and then you wait to get reimbursed.

Getting reimbursed is much faster than it was years ago. Thanks to electronic claims submission, you can see the dentist on Monday and usually get reimbursement before the end of the week. Also, many dentists accept credit cards, which typically have a monthly billing cycle. If you need complex treatment, speak to your dentist about arranging a payment schedule that allows you to budget for expenses.

Benefits of Non-Assignment

The main benefit of the assignment of benefits is the convenient payment process for patients. However, the ODA opposes the assignment of benefits; instead, we believe that non-assignment of benefits is best.

Why does the ODA oppose something most patients find convenient? Because non-assignment means that patients are more involved in their care and the costs involved. 

By being more involved you can:

• Have a better understanding of your dental plan and can use it wisely.
• Evaluate your dental plan and identify parts that could be improved.
• Develop the confidence to discuss fees with your dentist.
• Most dental offices can submit your claim for you electronically as a courtesy. If you need to submit your own dental claim form and need help, your human resources department or your dental plan administrator can assist you.

This article was adapted from the Ontario Dental Association: https://www.oda.ca/visiting-the-dentist/dental-benefits/

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Dental Coding

How to Properly Submit a Dental Claim During the Credentialing Process

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January 14th, 2021 | 8 min. read

Dilaine Gloege

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The challenge occurs most often when a treating provider joins a practice as an associate practitioner. During the credentialing process, practices are often tempted to submit claims using the already credentialed doctor or owner doctor listed as the treating provider. This is inappropriate because that provider may be receiving reimbursement he is not entitled to receive.

A non-credentialed associate treating patients with a PPO plan can create ill will between existing patients. As a practice, you want to continue to provide care at the negotiated rates for these patients while ensuring we are not submitting potentially fraudulent dental claims. 

This article will review how to submit legitimate claims and receive appropriate reimbursement while going through this lengthy process. The billing entity and treating provider sections of the 2019 ADA dental claim form will be reviewed to ensure the information entered results in appropriate reimbursement. Additionally, we will learn what an NPI number is and the difference in an NPI type 1 and NPI type 2 number and how it can delay claims processing. 

How is the billing entity reflected on the claim?

The billing entity or practice name is listed on the bottom left of the 2019 ADA dental claim form, and this indicates to the payer to whom the payment is issued. Basically, the billing entity information is who receives the insurance payment. This section must include the practice legal name or what name the practice is “doing business as” (DBA). What is also included in this section is the practice EIN (Tax ID) and the practice NPI type 2. 

Sorry, but get ready for the alphabet soup! An EIN is an Employer Identification Number obtained via the Internal Revenue Service (IRS). An EIN is similar to a social security number and identifies a business, or in this case, the practice or billing entity for tax purposes. 

An NPI is the National Provider Identifier and is part of Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. There are two types of NPI numbers: Type 1 and Type 2. 

The NPI type 1 identifies the healthcare providers who may be providing treatment or prescribing medication. All healthcare providers, including dentists were required to obtain an NPI type 1 number effective in 2007.

•  An NPI Type 2 number identifies the billing entity or practice and all treating providers associated with the practice. Centers for Medicaid and Medicare Services (CMS) issues and maintains NPI numbers. 

It is acceptable for a sole proprietorship to use the owner doctor’s NPI type 1 to identify the billing entity.

However,  it is advisable for any practice with more than one treatment provider to obtain an NPI type 2 number. The NPI type 2 number identifies the billing entity and all associated treating providers as a whole. 

Failure to obtain an NPI type 2 number when there is more than one treating provider can result in payment delays. For example, many federal plans will hold payment when a new associate is listed as a treating provider and the owner doctor’s NPI type 1 number is used to identify the billing entity. It can be a time consuming task to work with provider relations to obtain the backlog of held payments once the NPI type 2 is obtained.

Be proactive and obtain an NPI type 2 number before it becomes an issue. 

Who is listed as the treating provider?

The doctor who provided the treatment listed on the dental claim form or who supervised the hygiene services is listed in Box 53 on the bottom right of the 2019 ADA Dental Claim Form. This would be your treating provider. Always list the correct treating provider regardless of the in- or out-of-network status with the payer. Failure to accurately list the treating dentist results in a fraudulent claim being submitted. The treating doctor listed on the claim and the billing entity may receive reimbursement in which they are not entitled. 

How is the claim paid if the treating dentist listed is not credentialed yet?

This type of claim will be processed as out-of-network. Any available out-of-network benefits of the patient’s plan will be applied to the claim. Note that some plans have no out-of-network benefits. 

The out-of-network reimbursement may also be issued to the subscriber of the plan for treatment provided by an out-of-network dentist, regardless of assignment of benefits. Assignment of benefits is essentially who the insurance pays; the dental office or the subscriber/patient. This can be set up in any dental software. Within your dental software you should be able to indicate who to assign benefits on a per plan basis. In some instances, failure to properly assign benefits to the provider may result in the patient receiving the benefit reimbursement. This creates a collection issue between your dental practice and the patient. On the other hand, it could be that the patient paid the charge in full, and you fail to assign benefits to the patient mistakenly sending the payment to you instead. This can create ill will with your patient. Assignment of benefits laws vary by state. Know your state law to reduce any surprises and patient collection issues.

Can claims be submitted under the previous owner billing information?

So, you just bought a dental practice. Congrats!! Can you still submit claims under the previous dentist or owner? No. We are often asked if the buyer can apply the seller’s billing entity and list the previous credentialed owner as the treating doctor on the claim form. This is an inappropriate billing practice as it is misrepresentation. 

Once the sale of the practice has taken place, the new name of the practice and billing entity is accurately reflected in Box 48 of the 2019 ADA Dental Claim Form. This is effective for all dates of service on or after the sale of the practice. 

For the same reasons already discussed in this article, the previous owner cannot be reflected as the treating dentist on the claim form. However, what if the previous practice owner is now an associate of the new practice and actually performed or supervised the services listed on the claim? In this case, the previous owner now associate, will need to be recredentialed to connect her with the new billing entity. 

Do PPO payers allow special provisions for claim submission during the credentialing process?

You may contact each PPO payer in which you are credentialing to ask if there is a provision for submission during the credentialing process. Refer to your PPO contract and Provider Processing Policy manual/Dentist Handbook or contact the PPO provider relations department to inquire about such provisions. 

How can we avoid these challenges?

Credentialing can be a daunting task and one that requires patience throughout the process. Begin the credentialing process as soon as possible to avoid any reimbursement delays. Understand and implement proper claim submission during the credentialing process to ensure you are receiving appropriate reimbursement. 

Credentialing can be accomplished by your in-house dental team or by contracting with a credentialing specialist. Consider all options to make the credentialing process as smooth as possible. 

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Click on the questions below for the answer.

What is a pre-determination?

A pre-determination is an estimate of what treatment your dental plan will cover and what you will be responsible for. Your dental office will submit an outline of the proposed treatment to your dental plan provider prior to proceeding with treatment. It is an estimate only and does not guarantee the final costs you will be responsible for paying. It is important for you to be well informed on your plan coverage. Check with your dental plan provider to clarify when a pre-determination is required. Some plans may only reimburse some services if a pre-determination is received in advance of treatment. Also be aware that pre-determinations may be valid for a limited time; what is covered can change if you reach the financial limits of your plan; and/or other changes can occur to your plan before treatment is completed. The final treatment coverage is determined by your dental plan carrier. Any costs not covered are your responsibility.

My dental office tried to get a pre-determination for treatment; why did my dental plan provider decline it?

There are many reasons why a pre-determination may be declined. You may have reached the coverage limits in your plan or the treatment outlined may not be covered by your plan—the treatment plan is based on your health needs, not your plan coverage. It is important to understand that even if a pre-determination is approved, this is not a guarantee of coverage. Any costs not covered are your responsibility to pay. Review your plan coverage, and speak to your dental plan provider if you have any concerns.

What can I do to avoid any unforeseen dental costs?

Understand your dental plan. Know what coverage you have so that you can make informed decisions on what dental treatment services are covered and what treatment costs you are responsible for. Speak to your dentist about the treatment options and the importance to your health so you can make an informed choice for your health needs. Your dental office can work with you to provide an estimate and obtain a pre-determination prior to proceeding with treatment; however, they are not experts on your plan. Ensure you are aware of any changes and/or limits to your coverage and have let your dental provider know. Prevention is the best way to maintain good dental health and reduce the need for more costly and complex treatment in the future. Practice good oral hygiene at home and visit the dentist regularly to identify issues early.

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Exempt and nonexempt in the dental office: Classify correctly to avoid penalties

Exempt or nonexempt? In California, the distinction is a legal one. Wage and hour orders protect nonexempt employees, and employers who misclassify their employees can face steep penalties.

In California, all employees are considered nonexempt unless the employee’s role can be legally classified as an exemption under section 1 of the Industrial Welfare Commission’s wage order 4.

Exempt employees are paid a fixed biweekly or monthly salary and are not subject to many of the protections of California’s industrial wage orders. They do not receive overtime, are not subject to meal and rest break requirements and generally are not required to track their working hours.

Ensure employees qualify for an exempt classification

In general, an executive, administrative or professional exempt employee is in a position of management or possesses a decision-making role in the business. In the dental practice, the office manager may qualify for an exemption in the category of executive, administrative and professional employees. However, the employee must spend at least 51% of their time in a role on essential exempt duties. Not all manager duties are managerial, and a manager may spend most of their hours performing nonexempt duties such as scheduling and confirming patients and managing records.

Employers are responsible for analyzing staff positions following wage order 4 to determine proper classification. The analysis includes a review of not only the position’s activities and responsibilities, but its relative importance compared to other positions, the position’s necessary qualifications and the conditions under which the work is performed.

CDA’s members-only quick guide Exempt Employee Classification Compliance Checklist covers the requirements for the administrative, executive and professional exemptions. To be properly classified as exempt in any category, the employee’s responsibilities must meet all — not some — of the qualifications.

The professional exemption does not include dental hygienists except in very limited circumstances.

Exempt employees must earn at least twice the state minimum wage

Dentists may have read news about the U.S. Department of Labor’s rule effective July 1 that raises the minimum salary threshold for certain overtime exemptions.

The DOL rule does not impact employers in California, because the salary thresholds are higher in California per the following:

• Exempt employees must be paid a salary of at least two times the current state minimum wage for their full-time employment.
• Exempt employees’ salaries must meet the threshold of $1,290/week, $5,547/month, $65,560/year, which is higher than the federal standard.

Employers who misclassify an employee can be held responsible for actual damages owed for unpaid overtime and any corresponding fines, inaccurate wage statements, failure to provide required meal and rest period breaks and failure to pay overtime wages before the next payroll period.

“To avoid legal risk and, in some cases, attorney’s fees, carefully consider each classification and develop job descriptions to support the classification,” says CDA Employment Practices Analyst Michelle Coker.

For more details on wage order 4, exemptions and permissible and impermissible deductions, such as for paid time off and partial-day absences, CDA members can consult CDA’s Practice Guide to Employee Classifications in a Dental Practice. The guide also includes links to an exempt employee sample offer letter and related resources.

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HIPAA 20 Questions

Dentists often ask the ADA questions about HIPAA compliance. Here are 20 common questions that raise a variety of HIPAA issues. The topics range from determining who must comply with HIPAA to understanding certain HIPAA compliance requirements, such as distributing the Notice of Privacy Practices, dealing with Business Associates, and communicating with patients, their family members and others.

The ADA Practical Guide to HIPAA Compliance: Privacy and Security Manua l, available from the ADA Store or by calling 866.475.8366, provides information and sample forms and documentation to help dental practices comply with HIPAA.

HIPAA directly applies only to “covered entities” and "business associates." A dental practice becomes a covered entity by conducting a HIPAA standard transaction electronically or by having someone do so on the provider’s behalf. (See the next question for more information about HIPAA standard transactions.)

An example of a HIPAA standard transaction is the submission of an electronic claim. A dental practice becomes a HIPAA covered entity when it submits a claim electronically, or when it conducts another HIPAA-regulated electronic transaction, such as an eligibility inquiry or a claim status inquiry. HIPAA also reaches entirely paper dental offices that submit paper claims to a billing service that converts the paper into electronic format and submits the claims electronically for the dental practice.

The use of a paper-to-paper (non-digital) fax machine to submit claims does not, by itself, make a dental practice a HIPAA covered entity. However, if a dental practice is otherwise covered by HIPAA, the HIPAA Privacy Rule requires the dental practice to have in place reasonable and appropriate safeguards to protect the privacy of patient information in any format (for example, paper or other hard copy documents, photos, radiographs, oral and electronic information), which may include faxed data if the dental practice uses a fax machine to send or receive patient information.

Even if a dental practice does not meet the definition of a HIPAA covered entity, the dental practice may bind itself contractually to abide by HIPAA – for example, by signing a participating provider agreement that requires HIPAA compliance.

HIPAA empowers the government to impose substantial penalties against covered entities that violate HIPAA. HIPAA “business associates” must also comply with HIPAA and are subject to penalties for HIPAA violations (a business associate is generally defined as an outside person or entity that has access to patient information because it is performing a service on behalf of a covered entity). In addition, certain HIPAA violations are crimes and can subject individuals and entities to fines and imprisonment.

• Are You a Covered Entity?

The U.S. Department of Health and Human Services (HHS) has adopted HIPAA standards for several electronic transactions. These electronic transactions are used to exchange information about health care benefits and services among health care providers, health plans, clearinghouses, and, in limited circumstances, employers. Use of any HIPAA standard transaction makes a dental practice a “covered health care provider” that must comply with all HIPAA rules, including those for Privacy, Security, and Breach Notification.

The HIPAA standard transaction that is most likely to make a dentist a HIPAA covered health care provider is the submission of an electronic claim or equivalent encounter information. Also included in the definition of this transaction is the electronic submission of "encounter information," if the doctor’s reimbursement from a health plan is not based on claims for specific services. The transaction must be transmitted in electronic form; voice communications by telephone, or paper communications by non-digital fax typically do not count as “electronic,” although there may be some limited exceptions. There are also separate standards for electronic inquiries about the status of a claim.

Another common electronic transaction for which HHS has adopted a standard is an inquiry from a health care provider to a health plan about a patient’s eligibility to receive health care under the plan, a patient’s coverage under the plan, or benefits associated with the plan. Similarly, HHS has adopted standards for the electronic transmission of claims or payment information from any entity to a health plan for purposes of determining coordination of benefits.

Other relevant electronic transactions for which HHS has adopted a standard include electronically transmitted requests for authorizations for health care or for authorization to refer a patient to another provider. These transactions generally will be used by doctors who are under contract with an insurance company or health plan which requires them to obtain pre-authorizations for certain procedures, or authorizations to refer a patient to a specialist.

Finally, HHS has developed standards for the electronic transmission of payment information about the transfer of funds or payment processing information from a health plan to a health care provider’s financial institution. HHS also has developed standards for the electronic transmission of an explanation of benefits form or a remittance advice from a health plan to a health care provider.

For more information about the HIPAA standard transactions, see CMS, Are You a Covered Entity?

The standards are at 45 C.F.R. Part 162.

The HIPAA Privacy, Security and Breach Notification Rules impose a variety of requirements on covered entities and their business associates. Examples of key steps for covered dental practices include:

• Designate a privacy official and a security official
• Conduct a risk assessment of electronic patient information in your dental practice
• Develop and implement appropriate written privacy and security policies and procedures
• Develop the forms needed to implement your policies and procedures
• Prepare and prominently display a HIPAA-compliant Notice of Privacy Practices (NPP)
• Make copies of your NPP available to patients
• Protect patient privacy by taking appropriate precautions to prevent against inappropriate disclosure of patient information
• Adhere to HIPAA’s “minimum necessary” rule: when you use, disclose, or request patient information, limit your use, disclosure or request to the minimum amount of information necessary for the purpose (there are exceptions, such as disclosures for treatment purposes and disclosures to patients of their own information)
• Train your staff about your office’s privacy policy and practices. Impose sanctions for violations. Document training and the imposition of any sanctions.
• Enter into a compliant business associate agreement with each business associate
• Develop and implement a Breach Notification policy, train staff to comply, and provide any required notifications
• Maintain each of your HIPAA compliance documents for at least six years from the date it was created, or at least six years from the date when it last was in effect, whichever is later. Examples of HIPAA compliance documents include your NPP, written risk assessments, policies and procedures, designation of your privacy official and security official, training documentation (e.g., sign-in sheets), documentations of any sanctions for failure to comply, copies of any breach notification letters, and records of complaints and their disposition, if any, and signed business associate agreements.

If your dental practice is ever investigated or audited by the HHS Office for Civil Rights (OCR), the federal agency that enforces HIPAA, you will be asked to provide documents such as these to demonstrate compliance.

OCR has information about HIPAA compliance on its website.

Here are some examples of forms you may need to provide to patients or ask them to sign. The ADA Practical Guide to HIPAA Compliance Privacy and Security Kit has sample forms for dental practices to use as tools in developing their own HIPAA compliance programs.

Every patient must receive your NPP at his or her first appointment. In an emergency, provide the NPP as soon as reasonably practicable after the emergency treatment situation.

You must ask a patient to sign a valid authorization form before you may use or disclose his or her patient information for a purpose that is not permitted by HIPAA. For example, with certain exceptions, a patient must sign a valid authorization before your dental practice may make specific kinds of marketing communications or exchange patient information for remuneration.

If you discover a breach of unsecured patient information, you must send affected patients a letter containing specific information about the breach.

The NPP must contain certain specified regulatory language, and additional information in unspecified format about a variety of issues such as patient rights under HIPAA. The ADA sample NPP form (available in English and Spanish) includes examples of certain basic provisions required by HIPAA, and can be amended to take into account more stringent state privacy law.

OCR provides model NPPs

HIPAA requires you to give each new patient a copy of the NPP (see Question 4, “What forms must I give to patients or have them sign?”).

You must also have copies of the NPP available for individuals to request to take with them, and post the notice in a clear and prominent location. If you maintain a website that provides information about your services, you must also prominently post your NPP on the website and must make the NPP available electronically through the website. You may provide the NPP to an individual by email if he or she has agreed to electronic notice and has not withdrawn that agreement. If you know that the email transmission has failed, you must provide a paper copy of the NPP to the individual.

When you change or revise your NPP, you do not need to provide copies to each patient (although you should use the new NPP when giving a copy of your new NPP to new patients). You are only required to make the NPP available upon request on or after the effective date of the revision. Remember to replace the NPP that you have prominently placed in your dental office with the revised NPP, and to change the NPP on your website, if applicable.

You cannot refuse treatment solely because a patient refuses to sign an acknowledgment of receipt of your NPP. You are only required to make a good faith effort to obtain the patient’s acknowledgement. If the acknowledgement is not obtained, you should document your good faith efforts to obtain the acknowledgement and the reasons why the acknowledgement was not obtained.

HIPAA does not require patients to sign a form that says they agree to the policies in the NPP. HIPAA only requires covered dental practices to make a good faith effort to secure a patient’s acknowledgement that he or she has received your NPP (see Question 4 of this appendix, “What forms must I give to patients or have them sign?”). HIPAA does not require covered entities to obtain patient consent to the NPP.

If an applicable state law requires patients to sign a consent form, then you may be required to ask patients to sign the consent form. HIPAA does not preempt state law that is either not contrary to HIPAA, or that is contrary to HIPAA but is more stringent than HIPAA. A qualified attorney can provide information about what may be required in your state and how to develop a form that complies with all applicable requirements. Your state dental association may also have information about state laws that pertain to patient information.

Under HIPAA, dentists must have a compliant written business associate agreement in place with each of their HIPAA business associates (BA). HIPAA generally defines a BA as an outside person or entity that does something for or on behalf of a covered entity that requires the BA to access patient information.

Examples of BAs include attorneys, accountants, collection agencies, practice management consultants, computer software vendors, document storage firms, document destruction firms, and others who create, receive, maintain, or transmit patient information in connection with a function or service performed for or on behalf of a covered entity. A data transmission vendor may also meet the HIPAA definition of a BA. Health Information Exchanges (HIEs), and e-prescribing gateways are also BAs. The following are generally not BAs, so a business associate agreement would not generally be required:

• Members of the dental practice’s staff, such as associates, dental hygienists, and dental assistants under the dentist’s supervision and control (including temps and interns)
• Other health care providers to the extent that they are providing health care to a patient of the dental practice, such as specialists, physicians, pharmacies, dental labs, etc.
• Certain other covered entities such as insurance plans
• Banks, credit card companies and other institutions processing payment for patients
• The U.S. Postal Service and certain private couriers
• In general, plumbers, electricians, photocopy repair technicians, and janitorial services that clean the offices or facilities of a covered entity are not business associates

A covered entity may be a business associate of another covered entity. The list of BAs will vary from practice to practice. When assessing which individuals and entities are your BAs, come back to the question of whether you are giving that person or entity access to PHI.

The HIPAA definition of “business associate” is available in the HIPAA regulations at 45 CFR §160.103 , available from the U.S Government Publishing Office.

Under most circumstances, no. The HIPAA definition of “business associate” states:

Business associate does not include: (i) A health care provider, with respect to disclosures by a covered entity to the health care provider concerning the treatment of the individual.

Dental laboratories generally appear to fall under the HIPAA definition of “health care provider.” HIPAA defines “health care provider” to include, among other things, any person or organization who furnishes, bills, or is paid for “health care” in the normal course of business. “Health care” is defined by HIPAA to include, among other things, the sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription. Therefore, a covered dental practice is not required to enter into a business associate agreement with a lab, as long as the dental practice is disclosing patient information to the lab solely for purposes of the patient’s treatment.

The HIPAA definitions of “business associate,” “health care provider,” and “health care” are all in 45 CFR §160.103, available from the U.S Government Publishing Office .

It depends. Recall that a HIPAA business associate is generally defined as a person or entity who performs a service for or on behalf of your office, and who creates, receives, maintains, or transmits patient information in the course of providing that service. OCR includes the following in a list of situations in which a business associate agreement is not required:

When a financial institution processes consumer-conducted financial transactions by debit, credit, or other payment card, clears checks, initiates or processes electronic funds transfers, or conducts any other activity that directly facilitates or effects the transfer of funds for payment for health care or health plan premiums. When it conducts these activities, the financial institution is providing its normal banking or other financial transaction services to its customers; it is not performing a function or activity for, or on behalf of, the covered entity.

See OCR, Business Associates

So, the answer to this question will depend on the particular circumstances. If the financing company is providing services to the patient, then you likely will not need a business associate agreement with that company. If, however, the financing company is providing services to your office, and creates, receives, maintains, or transmits patient information in the course of providing those services, then you may need a business associate agreement with the company.

The ADA “Sample Business Associate Agreement” in the ADA Practical Guide to HIPAA Compliance Privacy and Security Manual illustrates how a dental practice might enter into a business associate agreement with a business associate. The ADA Sample Business Associate Agreement is designed to be used as a tool for covered dental practices and their attorneys to use to develop a compliant business associate agreement between a dental practice and its business associate. Use of the ADA Sample Business Associate Agreement does not replace consultation with a lawyer or negotiations between the dental practice and business associate.

The HIPAA Privacy and Security Rules require that certain provisions be included in a compliant business associate agreement. Such provisions are included in the ADA Sample Business Associate Agreement. However, the parties to the agreement may also wish to include other provisions, such as provisions that relate to limitation of liability, indemnification, and insurance. Examples of certain optional provisions are included in brackets (“[ ]”) in the ADA Sample Business Associate Agreement.

In addition, certain other provisions may be included in a business associate agreement in compliance with applicable state law. For example, additional provisions may be necessary to create a binding contract under state law. Also, state law that is more stringent than HIPAA may require changes to the business associate agreement. A qualified attorney can help a covered dental practice develop a business associate agreement that complies with applicable federal and state law for use in a specific contractual relationship.

Some business associate agreements are styled as attachments or amendments to an underlying contract between the dental practice and the business associates, and others are stand-alone documents that may refer to an underlying agreement. The ADA Sample Business Associate Agreement is styled as a stand-alone document with a space for inserting a reference to the underlying agreement.

The business portions of the underlying contracts between covered entities and their business associates vary greatly  –  who does what, for whom, when, for what payment, on what terms and conditions, for how long, etc. Some contracts may be simple, others more complex. Some may be susceptible to significant negotiation, others perhaps not. Some may trigger other federal, state or local law and regulation; others may be free of such concerns.

Because the business aspects of each contract will vary, a business associate agreement is frequently drafted as an addendum to the underlying contract, or as a stand-alone agreement that refers to the underlying contract. Once the parties negotiate the business components of the contract, the addendum can be used to cover provisions required by the HIPAA Privacy and Security Rules by either incorporating the addendum directly into the contract or by reference to the addendum as an attachment to the contract. However, business associate terms may be incorporated into the underlying agreement instead.

The terms of each business associate agreement may vary depending on the nature of the contract involved, the relative bargaining positions of the parties, and so forth.

No. A covered dental practice is not required to sign a business associate agreement with the subcontractors of a business associate. That is the responsibility of the business associate.

A business associate must enter into a written agreement with subcontractors that will create, receive, maintain or transmit patient information. The agreement must contain certain required provisions and must require the subcontractor to appropriately safeguard the patient information. Like business associates, subcontractors must comply with many parts of HIPAA, including most of the Security Rule, and the government can directly impose penalties on business associates and subcontractors, as well as on covered entities.

Not surprisingly, some HIPAA business associates have their own business associate agreement forms and refuse to sign the business associate agreement proposed by the covered entity. Some business associates say that they will not negotiate any of the provisions of their business associate agreement form. If a business associate insists on using its own form, a covered dental practice will want, at the very least, to be sure that the business associate’s form satisfies the requirements set forth in HIPAA and any applicable state law.

We are also hearing that some business associates are refusing to sign any business associate agreements. HIPAA requires a covered dental practice to obtain a compliant business associate agreement prior to permitting the business associate to create, receive, maintain or transmit patient information. Refusing to sign a business associate agreement does not change a business associate’s HIPAA obligations or protect the business associate from government penalties for noncompliance.

In such cases, the dentist should find a more HIPAA-friendly vendor or service to provide the BA services in question.

You can remind patients of appointments, but you should restrict the information that others may be able access (for example, on a postcard or in an email, text or voice message), and you should accommodate any reasonable requests by patients to receive communications by alternative means or at alternative locations.

Keep in mind that under HIPAA, you must protect patient privacy by taking reasonable precautions to prevent incidental disclosure of protected health information and by adhering to HIPAA’s “minimum necessary” rule regarding the use and disclosure of such information. The safest course is thus to be discreet in reminders.

Using a patient’s name and the date and time of appointment to provide a reminder at the telephone number or address that the patient provided is generally fine. On the other hand, disclosing specific information about treatment, health conditions, pre-medication, and so forth can cause problems. Someone other than the patient may see the recall card or listen to the answering machine message. Emails and text messages may be accessible to third parties (for example, while they are in transit).

If there is a need to reveal information other than name and the date and time of the appointment, consider putting the message in an envelope or asking the patient to call the office. Another approach is to have the patient sign a HIPAA authorization in advance, giving you permission to leave specific messages about appointments, even if they may be seen or overheard by others.

HIPAA requires covered dental practices to permit patients to request to receive communications by alternative means or at alternative locations. Covered dental practices must accommodate such requests if they are reasonable. A dental practice may require such requests to be in writing, may require information as to how payment, if any, will be handled, and may require the patient to specify an alternative address or other method of contact. A dental practice may not require an explanation from the patient as to the basis for the request.

First, if you are dealing with minor children, the HIPAA Privacy Rule generally defers to state law to determine who can be a patient’s “personal representative,” with authorization to access and make decisions about the patient’s information.

Resolving this question can be tricky when the child’s parents are not married and only one parent has custody. Generally, HIPAA permits a child’s parent or legal guardian to access the child’s patient information. However, if a person other than a parent or guardian brings the child in for an appointment, it is sometimes less clear whether the child’s patient information may be discussed with that person. Generally, it would be best to obtain permission from a parent or guardian before talking to a third party, such as another relative or a nanny, about that child’s health care.

Generally, if your state’s law would allow a parent or other person to make decisions about the child’s health care, then that parent or other person may also have access to and make decisions about the use of the child’s PHI. When in doubt about questions of state law, consult your state dental association or your personal attorney.

State law will also affect your dealings with adult patients. Typically, unless the patient has a court-appointed guardian or has legally designated another person to make health care decisions, that patient has the right to make decisions about his or her health care information, regardless of any disabilities or communication difficulties. Of course, if you feel that it would be helpful to involve a family member or friend in discussions of the patient’s health information, ask the patient if this would be acceptable and proceed if this is OK with the patient. However, never assume without asking that, merely because a patient is older or is facing some challenges, it is permissible to disclose that patient’s protected health information to a relative, friend or caregiver.

More information is available in the following OCR resources:

Communicating with a Patient’s Family, Friends, or Others Involved in the Patient’s Care

Personal Representatives

HHS has indicated in guidance that covered entities and their business associates may disclose patient information for payment purposes to persons other than the patient who are responsible for payment, as long as the disclosures are limited to the minimum amount of information necessary to obtain payment. In making such disclosures, dental practices must honor any restriction on the use or disclosure of the patient’s protected health information to which the covered entity has agreed.

Keep in mind that, with limited exceptions, HIPAA requires a covered dental practice to permit a patient to request the dental practice to restrict uses or disclosures of the patient’s information to carry out treatment, payment or health care operations. With one important exception involving disclosures to health plans (which we will discuss below), the dental practice is not required to agree to a requested restriction. However, if the dental practice agrees, the dental practice must honor the restriction except in certain emergency circumstances. A dental practice must document any agreed-upon restrictions. Except for restricted disclosures to health plans discussed below, a dental practice may unilaterally terminate a restriction by informing the patient; however, a unilateral termination is not effective for patient information created or received after the termination. A dental practice that uses or discloses patient information in violation of an agreed-upon restriction may be in violation of HIPAA.

If the patient objects to such a disclosure, you may wish to inform the patient that he or she will have to choose between allowing you to disclose information in order to obtain payment, or paying for the services himself or herself.

Restricted disclosures to health plans . HIPAA requires a covered dental practice to agree if a patient asks the dental practice not to give the patient’s information to the patient’s health plan, as long as the information:

• Is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and
• Pertains to a health care item or service for which the patient or someone else (including a different plan) has paid the dental practice in full.

The dental practice cannot terminate this kind of restriction unless the patient agrees.

Yes, under the HIPAA privacy regulations and quite possibly under your state law as well. The HIPAA Privacy Rule provides that patients have certain rights to see and get copies of their records. There are limited exceptions, including, for example, information compiled in reasonable anticipation of, or for use in, legal proceedings. A healthcare provider also may deny a patient’s request for access to his or her records in certain circumstances, such as if the records requested were obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.

If none of HIPAA’s grounds for denying access applies, the Privacy Rule sets forth how a dental practice must respond if a patient asks to see or get copies of his or her patient information. For example, the dental practice may impose a “reasonable, cost-based fee.” This fee must be limited to the costs of supplies for and labor of copying, postage (if the patient requested the copies to be mailed), and preparing an explanation or summary of the records, if the patient agreed in advance to receive a summary or explanation and agreed in advance to the fee for its preparation. Dentists may not charge for time spent locating, searching or retrieving records. This HIPAA fee limitation only applies when patients ask for copies for themselves. The fee limitation does not apply when a patient asks for a copy to be sent to a third party, or when a third party with the patient’s authorization ask for a copy of patient records. Covered dental practices must comply with applicable state law that is more stringent than HIPAA. For example, if state law requires dentists to provide copies at a lower cost or no cost, dentists must follow state law.

Yes. You may have noticed that the answer to Question 18 of this appendix mentions an exception for information compiled in reasonable anticipation of, or for use in, legal proceedings. However, this exception refers to information or documentation compiled in addition to a patient’s dental record, in anticipation of or for use in legal proceedings.

If a patient asks the dental practice to send his or her records to someone else, the request must be in writing signed by the patient, and clearly identify the designated person and where to send the copy. Generally, the HIPAA privacy regulations would not require you to obtain a written “valid authorization” from a patient in order to transfer his or her records to another health care provider for purposes of treatment. However, applicable state law may require you to obtain a consent or authorization under these circumstances. Check with your attorney or your state dental association.

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