Dental plan co-payments
Many dental plans have co-payments, a percentage of the claim amount that is not covered by the dental plan. These co-payments are usually 20% - 50% of the claim amount. Many dental patients believe that the dentist can waive these amounts so that the patient doesn't have to pay the money. This is not the case and the consequences for not making a reasonable attempt to collect the co-payment are very serious.
Under the Dentistry Act, 1991 (Regulated Health Professions Act) dentists are required to make a reasonable attempt to collect the co-payment portion of dental fees for which the patient has payment responsibility. The profession's regulatory body, the Royal College of Dental Surgeons of Ontario (RCDSO), is responsible for ensuring dentists adhere to this requirement.
The dentist has a professional obligation to collect the co-payment. On some occasions, the dentist may run into difficulties doing so. On these occasions, the term "reasonable" should be assessed taking into account the circumstances of the situation.
This includes occasions when it is clear to the dentist that the patient cannot afford to pay the co-payment. The dentist may then decide to cease pursuing the collection. The following options are open to make sure that the dental plan administrator is not misled:
- citing the reasons why this decision has been made, the dentist can advise the dental plan administrator of the situation and obtain his or her consent in writing to cease attempting to collect the co-payment and
- also stating the reasons why, the dentist could advise the dental plan administrator that he or she does not intend to collect the co-payment, and that he or she will accept as full payment, the amount the plan administrator will pay under the plan.
In either of these scenarios, no attempts to mislead the dental plan administrator have been made. Intentional misrepresentation by the dentist can result in discipline by the RCDSO, loss or suspension of dental registration and criminal proceedings for insurance fraud. Insurance companies also reserve the right to request that the patient provide proof that the co-payment has been paid. If the patient is unable to provide that proof, the insurance company may demand the patient make financial restitution to the insurance company or it may apply the overpayment to future claims.
Clearly, waiving the co-payment and misleading the plan administrator jeopardizes everyone involved - the dentist, the plan administrator and the plan sponsor. Your dental plan is not a treatment plan. Information courtesy of the ODA (www.oda.on.ca)