Do You Charge an Added Fee for PPE?

Michael W. Davis, DDS
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There is no doubt that dental offices are incurring additional expenses due to the costs of personal protective equipment (PPE) related to the COVID-19 pandemic.

Because of PPE shortages, some vendors are price-gouging in their PPE sales. Others are going further and distributing counterfeit PPE.

Compounding issues of inadequate and costly PPE are health guidelines for social distancing, which directly impacts patient scheduling and reception room occupancy.

Many dental facilities have added a PPE fee for each patient visit to remain fiscally viable. The ADA supports this surcharge.

“Dentists should develop a standard office policy to document the additional PPE that will be used across all patients. This documentation methodology will justify a standard fee across all patients,” the ADA said.

“Alternatively, dentists may wish to add a note in the patient’s record to document the details of PPE uniquely necessary for the visit when charging different fees based on the level of PPE used,” the ADA continued.

“When adjudicating such claims, the ADA believes that it is inappropriate for any third party benefit program to unfairly place the cost burden on dentists by disallowing or bundling charges for PPE on the pretext that the payment for additional required PPE is included in the payment for any other procedure billed for the visit. Denied claims are typically billable to the patient,” the ADA said.

“Prior to such adjustments taking effect, dental offices may wish to use CDT code ‘D1999 – unspecified preventive procedure, by report’ to document and report the use and cost of additional PPE. Dentists can use this code once per patient visit/claim to attempt to cover the cost of PPE,” the ADA said.

Maryland

Maryland Attorney General Brian E. Frosh has advised dental patients in his state that surcharges by some dental providers could violate the Consumer Protection Act.

“Dentists may once again provide elective and non-urgent care if they comply with the Secretary of Health’s May 6, 2020 Order requiring enhanced infection controls, but some providers may be improperly imposing additional fees,” Frosh said.

Frosh also sent a letter to the Maryland State Board of Dental Examiners and the Maryland State Dental Association advising them that his office’s Health Education and Advocacy Unit (HEAU) has been receiving complaints that some reopened dental practices have been charging patients increased fees by collecting additional, upfront amounts for the costs of enhanced infection controls including PPE.

“As part of its standard mediation efforts, the HEAU is informing consumers and dentists of the Office’s position that the imposition of additional fees, particularly those charged upfront to all patients, may violate the Consumer Protection Act’s prohibition against unfair or deceptive trade practices because typical provider-carrier contracts, as well as public and private insurance laws, prohibit participating providers from charging such fees to insured consumers,” Frosh said.

The conflict between the perspectives of the Maryland Attorney General’s Office and the ADA is starkly evident.

The Insurance Industry

We’ve recently begun to witness dental insurance carriers allowing a patient benefit fee for coronavirus PPE under the ADA Code on Dental Procedures and Nomenclature (CDT). The applicable billing code is D1999. Other dental insurance companies have denied such billings and allege this activity represents unlawful “unbundling.”

“As dental offices prepare to open, United Concordia Dental is helping protect the safety of our members, dentists, and dental office staff by helping cover the cost of personal protective equipment (PPE) recommended by the American Dental Association for dentists in all of our PPO networks,” said Walter J. Cherniak, senior communications analyst for United Concordia (UC) Dental Insurance.

“For dates of service from May 1-June 30, we’ll reimburse dentists $10 per patient per visit to help offset their PPE expenses for all fully insured clients. With dental offices beginning to reopen across the country, we are evaluating extending the dates,” Cherniak said. “By supporting dental patients, dentists, and office staff, United Concordia is promoting the delivery of high-quality care in a safe environment.”

Also, Humana will pay an additional $7 per member dental claim for all fully insured dental members to offset increased infection control costs during the pandemic. At the end of each month, the company will send a stipend to its dental provider partners based on the total number of claims for its members that month.

“Humana understands how the pandemic has impacted so many of the dental practices we work with, and it’s important to us to support them as so many are in the midst of reopening their practices,” said Chris Hunter, president of Humana’s Group & Military Segment.

“Our goal with the new actions we are taking is to help ensure that our dental provider partners can afford the personal protective equipment they need to safely treat their patients, our Humana members,” said Hunter.

The individual state operations in the Delta Dental network have been providing a variety of programs to support these costs. Delta Dental of Tennessee’s Operation #SmilesMatter offers dentists $1,000 grants for supplies, equipment, and technology. Delta Dental of Massachusetts will provide $10 payments for each in-person patient visit completed between June 1 and August 31 to help reduce barriers to care too. Delta Dental of Virginia is distributing $3 million to more than 4,500 dentists in its network to cover operating expenses associated with safety guidelines. 

Meanwhile, 36 states have enacted statutes allowing dentists to charge for non-covered services, even while operating under a signed preferred provider organization (PPO) insurance contract. Insurers are prohibited from interfering with contracted doctors who provide patients with non-covered services, as long as these patients clearly understand the service is not a covered benefit.

The ADA has forcefully advocated that third-party payors modify fee schedules, due to unanticipated additional PPE expenses. The ADA contends that third-party benefit programs should adjust the maximum allowable fees for all procedures or allow a standard fee per date of service per patient to accommodate the rising costs of PPE. The ADA further says that not doing so is deemed an automatic reduction in reimbursement rates.

Experts Weigh In

“A question that keeps coming up currently is ‘should dentists charge a separate fee for infection control or should the infection control costs be absorbed in the total treatment fee?’” said noted clinician Gordon J. Christensen, DDS, MSD, PhD.

“If dentists have been keeping up to date with their infection control policies pre-COVID-19, they already had almost the same costs as currently, which we have determined is close to $20 for one patient seating with one dentist and one assistant,” said Christensen. 

“Of course, this cost has gone up due to insufficient supply of PPE. That will soon come back down since supplies are now meeting demand in most areas. If dentists were not keeping up with CDC recommendations, then yes, infection control costs will be somewhat higher for them,” said Christensen.

“As this media stimulated pandemonium calms, most dentists will go nearly back to pre-COVID infection control policies with a few improvements, as happened in numerous previous pandemic virus situations,” said Christensen. 

“Some surveys show that the majority of patients object to a separate charge, apparently due to the historical lack of such fee. Although there are various opinions on this topic, the best PR orientation is to not charge a separate fee. Very few patients will even know if the clinical fee is a small amount higher than before. That is my personal policy. You are welcome to disagree,” said Christensen. 

Mac Lee, DDS, a long-standing dental practice management consultant and speaker, also offered his perspective.

“I graduated dental school in 1972 and practiced with my father. No gloves, ever! We both did a tremendous amount of surgery and periodontal treatment with blood everywhere. I wore the same couple of neckties during the week. Never really washed those wicks of bacteria and no telling what else,” Lee said. 

“In the early ’80s, AIDS hit the scene. Being an early adopter and seeing the writing on the wall, I started wearing smocks, gloves, and masks and forced the team to do the same. We did implement an infection control fee. It did not create that much of a problem at that time because it was 100% new to everyone, so the consumer understood the need,” Lee said.

“Now, most consumers feel that dentistry has always been on the forefront of infection control, and not that much change is visible to them. I think we should continue to be the gold standard of infection control. What if restaurants charged infection control? What if they charged double because they can only see 50% occupancy?” Lee said.

“I will not be charging for extra PPE. I will raise fees that are not fee sensitive. Hygiene is fee sensitive because people know what you charge every six months. They don’t know about the other high-end fees,” Lee said.

Conclusion

No dental practice can operate at a financial loss and survive for any length of time. Such a fundamental economic principle may be beyond the grasp of certain government officials.

This concept is certain to be tested to the extreme, especially in the dental Medicaid sector. Profit margins are thin, and patient volumes are high. A strict fee-for-service practice may easily absorb added PPE overhead. By contrast, a Medicaid or discount PPO-focused practice may struggle to capture fixed per patient costs of doing business.

Well-meaning edicts and pontifications from governmental poohbahs may easily generate unintended consequences. Disadvantaged citizens may have an ever-increasing challenge in accessing dental care, as numbers of providers opt out of programs that fail to adequately cover overhead costs.  

A lower fee structure practice depends on high patient volume and rapid patient turnover. Fixed costs for PPE are less easily offset because few higher-profit cases are delivered. In fact, many Medicaid dental clinics were already remiss for proper infection control even prior to the COVID-19 outbreak. The squeeze will only get tighter under our new reality.

Added significance is thrust into the modern salutation, “Stay safe.”

Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at mwdavisdds@comcast.net or smilesofsantafe.com.

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