Many businesses, including dental practices, offer senior citizen discounts. For example, a dentist may offer a 5 percent price reduction to all patients age 65 and older. Discounts in and of themselves can be perfectly legal, but it is important for dental teams to correctly offer and report discounts.
Discrimination
If a dental practice offers a senior citizen discount, this discount should be offered to all senior citizens who are patients of the practice. This can be considered a legal protocol. For example, if the practice offers a 5% senior citizen discount to patients over the age of 65, this discount must be extended to ALL patients over the age of 65. There should be a written protocol in place that clearly states the age at which a patient is considered a ‘senior,’ and never left up to the discretion of a team member. If a discount is not offered for reasons such as assumed ability to pay, having a “good” insurance plan with a high reimbursement, or similar, it may be considered price discrimination, an illegal protocol.
For example:
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Mr. Jones is 66 years old, with a great insurance plan that reimburses 100% of the full practice fee.
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Mrs. Smith is 64 years old, uninsured and has mentioned several times that she doesn’t know how she is going to pay for treatment.
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If the practice has a policy in place offering a 5% senior citizen discount for patients age 65 and older, Mr. Jones would receive the 5% discount. Mrs. Smith will pay the full practice fee out-of-pocket.
Reporting Discounts
The practice is required to submit the actual fee charged for any service(s), including any discounts, on the claim form. This applies to both medical and dental claims. Any discount given, including a senior citizen discount, should be deducted from the full practice fee and the remaining fee should be reported on the claim form (not the regular full practice fee).
Often, the “full fee” in dentistry refers to the practice standard, usual and customary fee. However, when submitting the full fee on a dental claim form, always submit the actual fee the dentist intends to accept as payment in full for the service(s) rendered.
For example:
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If Mr. Jones above receives a 5% senior citizen discount off of an exam with a full practice fee of $100, the fee reported on the claim form would be $95.
Reporting a fee higher than the actual fee charged to the patient is not only unethical but may be considered overbilling by payers, a potentially fraudulent act.
Forgiveness
Discounting the patient’s portion is considered copay forgiveness. Every state has laws against copay forgiveness and PPO contracts specifically prohibit any type of deductible or copay forgiveness. In addition, Medicare, Medicaid, FEDVIP, and military dependents are prohibited from receiving copayment forgiveness. It is the dentist’s responsibility to make a good faith effort to collect the patient’s coinsurance, copayment, and/or deductible.
Furthermore, there is a provision of the contract between the patient and insurance payer that the patient agrees to pay any portion of the fee not covered by the plan. The patient’s signature or “signature on file” is entered in Box 36 of the 2019 ADA Dental Claim Form. By signing Box 36, the patient agrees to the following statement:
“I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim.”
For example:
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Mrs. Cruz is 70 years old and has an insurance plan that reimburses 50% for crowns.
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If the practice has a 5% senior citizen discount policy in place for patients over the age of 65 and the full practice fee of $1000 for the all-ceramic crown she needs on #19, the amount reported on the claim form would be $950 (not $1000).
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Mrs. Cruz would pay $475 out-of-pocket and insurance would reimburse the remaining $475.
Dentists offering senior citizen discounts should be aware of any state laws that may apply and should consult with an attorney prior to implementing this billing practice. Additionally, the discount should be offered to all senior citizens, regardless of their willingness or financial means to pay a higher fee.
Have a clear written policy (that adheres to all prevailing state and federal regulations) outlining the age requirement and amount of discount given and offer the discount to all patients who meet the practice’s established criteria.
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