Are you one of the doctors who discovered your PPO agreement because you were asked to write off a significant amount for a procedure? Maybe you were made aware of the provisions outlined in the manual after a claim denial, an audit or grievance filed by a patient.
Most practices consider only the negotiated fees when joining a Preferred Provider Organization (PPO). Joining a PPO is much more than the fee agreement. You want to avoid costly missteps when billing for procedures, especially when adjusting fees. The PPO contract requires the provider to adhere to the payer's processing policies. These policies are found in a manual referred to as a processing policy manual, dentist handbook, dentist reference manual, etc.
To keep peace with your patients, and keep your practice compliant, you’ll need to have the PPO policy manual handy. This manual is a document separate from the contract. The document's name can vary by payer but should be referenced in your agreement. For this article, we will refer to it as the processing policy manual.
After assisting thousands of doctors, office managers, and insurance coordinators solving insurance challenges, I find it alarming that most are not aware of this processing policy manual. Signing a PPO contract is not to be taken lightly. Always read the agreement before signing. Understand each provision and how it may affect your practice. This article will address how to get a current copy, and some of the common provisions outlined in the processing policy manual.
How can we obtain the policy manual?
The manual as stated, is usually a separate document from the contract. You can get one by requesting from your PPO provider relations representative or by logging in and downloading one from the provider website.
Delta Dental, in some states may have two such manuals: a state handbook and the national USA policy manual. For participating Delta Dental providers, including those enrolled in Delta Dental Premier, there may be two separate processing policy manuals – the practice's state processing policies and the Delta Dental National processing policies. Delta Dental in some states have combined the two so it may just be one manual.
Why may there be two manuals?
Some dental plans adhere to the local Delta Dental policies while some are national accounts and adhere to the Delta USA National processing policy manual. An example of a Delta Dental national account is Walmart. Walmart is a self-funded plan administered by Delta Dental of Arkansas that follows the Delta Dental USA National Processing Manual. When a claim from Wal-mart is processed, all provisions of the national processing policy manual are applied to the claim.
What are common provisions of a processing policy manual I should be aware of?
Note that a dental plan contract provision will supersede any PPO contract processing policy provision. Let’s look at examples:
Employer plan A: The patient is responsible for the difference between the total fee and the PPO’s payment. The plan provides reimbursement of an amalgam for all composite restorations placed in a molar tooth. The plan also states that the patient is responsible for the difference in the total fee billed and the amount paid. This means you bill the patient, and collect your full fee -- You benefit because you collect your full fee billed – no write off.
Employer plan B:The practice has a write-off. A self-funded employer plan administered by Delta Dental. The plan provides reimbursement of an amalgam for all composite restorations placed in a molar tooth. The plan also states that the patient is responsible for the difference in the allowed amount of a composite restoration plus any coinsurance and deductible. The practice would have a write-off of the difference between the full fee billed and the allowable fee of a composite restoration.
Read all Explanation of Benefits (EOBs) carefully including all remarks to ensure you are not adjusting more than you should. It is the types of examples given that are often missed or misunderstood. If in doubt, contact the payer for clarification of what can or cannot be billed to the patient.
Appointment wait time requirements may be outlined in your manual. For example, your payer manual may state that all emergency patients must be seen or referred for care within 24 hours of contact. Another is hygiene appointments requests must be offered appointments within 8 weeks of contact. This varies greatly. It is also important to note that some states have legislation regarding appointment times – access to care. Know your state law.
Benefits are determined based on procedure completion date. Most processing policy manuals state that no claim can be submitted until the service is completed. Also, you will likely find the language indicates that reimbursement is based on any benefits available at completion date.
All services must be submitted. This provision is often overlooked and can be problematic for a practice in an audit situation. What this means is all services rendered must be submitted to the payer. You may find language such as “all services for which there is a charge must be submitted.” Some may state “all services must be submitted.”
Remember that a payer can change these policies. Any provision outlined is subject to revision at any time by the payer with proper written notice given, usually within 60 days of the effective date of the change in policy.
There's a lot to know when working with PPOs
As you can see, there is much more than fees to consider when in-network. Understand fully what you have agreed to. Read contracts and processing policy manuals along with any updates to the payer policies. Don’t be caught off guard and find you are in violation of your agreement because you failed to obtain and read your manual. If there is any question, you should contact your provider relations representative or department for clarity.
Make it a priority to keep your practice compliant
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Disclaimer: The information in this article is for training and educational purposes only and is not intended to be considered legal advice. The author is not an attorney. For a legal interpretation of your PPO agreement and processing policy manuals, consult with a healthcare attorney knowledgeable of your state healthcare laws and dental PPO agreements.