Can Patients Choose Not to Use Their Dental Insurance?

Insurance is often a massive headache for many offices. However, it does not have to be. Don’t get me wrong, it will always be an annoyance, but insurance handled well should not be a stressor.

If you are a network provider, you know that your provider agreements require you to file claims with the insurance carrier. I am not suggesting you breach these contracts; however, the patient is the higher authority. It is our obligation to let patients know what their payment options are. 

Thanks to HIPAA/HITECH regulations, as of 2009, you can allow a patient to opt out of filing their health insurance where the situation warrants. So let me explain when opting out can make good sense.

The most common reasons to opt out is when a treatment is not covered by their insurance plan, or the patient wants an enhanced treatment or quality of material that insurance doesn’t cover. Any procedure that a patient wants which is not feasible to do under massively reduced fees (veneers, cosmetics, nitrous, sedation, hybrid pros, etc.) the patient can opt to not involve insurance at all for that procedure. This allows you to find a mutually beneficial treatment option/cost with the patient and completely prevent insurance from ever getting involved in the future in trying to dictate your fees. 

If after discussion and explanation, a patient elects to opt out of their insurance, you should have them sign an “Election to Self-Pay” form. By signing this form, the patient is stating that they have chosen to opt-out of their insurance and by doing so, you will not be filing a claim with their insurance company. The Self-Pay form works on all private PPO in-network plans.

These laws governing HIPAA and the ability to opt out are federal in nature, so the only plans to be concerned about are federal plans (Medicaid, TriCare, GEHA). With a federal plan, if you are in-network you either follow their stated treatment fee schedule or refer the case out.  

The conversation with the patient should go something like this:

Team Member: “Mrs. Jones, we verified your insurance benefits, and they will not pay for X treatment at all (or insurance will not allow us to provide you the level of quality you are seeking). Most patients tell us they don’t want to sacrifice quality just to satisfy the insurance company’s requirements. You have the option not to involve your insurance carrier for this procedure and pay us directly, or we can refer you to someone out of network who can do this work for you. What would you prefer to do?”

OR

Team Member: “Mrs. Jones, many of our patients who see the benefit in a medical procedure yet whose insurance plan has restrictions like yours choose not to involve the insurance company and choose to sign up for a membership plan instead. Would you like more information on this?” 

Patient: Sure, how do we do that?

Team Member: If you choose to opt out involving insurance for this procedure, there is a simple HIPAA form to sign that outlines the process. This will allow us to provide the quality care you want and deserve.

If you’re a member, you can find a sample copy of this form by visiting the Downloads page and accessing: Do Not Bill to Insurance: Patient HIPAA Restriction Request Form.