I have a insurnace question:
Say that Dentist Joe is in Network with BlueCross Blue Shield They have agreed in their signed PPO contract that Dr. Joe will do crowns for 600.00. Dr. Joe calls this crown his Regular Crown. However, Dr. Joe has another level called the super duper duper crown. He utilizes a totally different lab, puts more levels of shading, really makes it shine. He has a 500.00 elective upcharge.
So Chris the patient comes in and needs a crown. Dr. Joe says, “Chris you can get the regular which your insurance will cover, but for just a few bucks more I will give you the super duper duper which will look great!”. I say “o.k. Dr. Joe lets do it!”
Dr. Joe submits the regular crown to insurance to get his 600.000 from BCBS. He also pockets the additional 500.00 buck and has a signed authoriztaion of understanding from Chris stating he fully knew the dealio.
Is this o.k.?
Whatever procedure the doctor performs must be within his contratual guidelines. Meaning if he charges the patient an extra fee he must report that fee to the carrier, otherwise, this maybe considered a form of fraud.
American Dental Coders Association
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