First, let's cover what a downgrade is.
A downgrade or dental insurance downgrade occurs when insurance companies elect to pay for the least expensive procedure if there is more than one acceptable option. In this situation, the patient can receive any treatment but if they elect for the more expensive (non-covered option) they will have an increase in out of pocket portion. Filings and crowns are often downgraded.
What is a posterior downgrade?
Let's say a patient has a traditional 100/80/50 plan and fillings are covered 80%. However, the insurance company downgrades on posterior teeth to an amalgam restoration.
$100 Posterior Composite
$ 80 Amalgam Composite
Since the benefit is the amalgam, the insurance coverage is $64.The patient will pay $36. Even though they have 80% coverage, we must factor the coverage on the allowable fee of the Amalgam Composite.
Can I charge a patient the difference for a downgrade?
YES. You are allowed to charge the difference to the patient.
Are insurances allowed to downgrade procedures even if we are out of network?
YES! It does not matter if a dental office is in or out of network. The provisions of each plan are governed by the insurance. In network status does not determine if downgrades apply to a patient.
How do I get my dental software to factor downgrades in a treatment plan?
Check to see if your dental software has a payment table. This may be called something different in your software. However, if you have this it would be an area that allows you to type in the actual payment you will receive from the insurance company. This is not to be mistaken for the fee schedule. When you find a patient has a downgrade, simply change the payment to the amount expected for the downgraded procedure.
Example:
Expected reimbursement:
$80 for a composite filling
$64 for a amalgam filling
Add an entry to your payment table for the composite filling to be $64. This will generate a proper patient copay when you generate the treatment plan.
My old office manager said when there is a downgrade, just change the percentage for the downgraded procedure by 10%, is that right?
No, Nope, Not at all, Don't Listen....
I have seen this about 1,892,362 times and it drives me insane. Do not, I repeat, do not change the percentage of coverage for downgrades. That is not how it works. The insurance pays a percent for that service. They are not telling you that they pay a different percentage, they are saying we pay a different fee. Always go back to the procedure they are downgrading, find the fee then multiply the % so you can get the actual reimbursement. Update your payment table so you do not have to figure this on every patient in that same group.
How do I explain to a patient they have a downgrade but they still need to have the treatment?
[Insert Insurance Company Name] provides what is called an alternate benefit for [insert treatment diagnosed]. Your copay is $______.
Our thought is "why make a big deal out of something that does not have to be a big deal?" A lot of sentences just become a lot of sentences. Say what it is and what their cost is. If you dig too deep, you will meet objection and may risk completing treatment. If the patient asks questions, explain the risks associated and your best practices. It starts with knowing the patients desires, fears and reason for wanting you to take care of them. Uncover what is important to them and this conversation will not be as difficult as you think.