Information Released on Balanced Billing Issue for Dentists

July 27, 2020 | Article

Further guidance issued on HHS Provider Relief through FAQ Response

The Department of Health and Human Services (HHS) recently opened up the HHS Provider Relief Fund to all dental practices. This fund was part of the $2.2 billion CARES Act and represented approximately $175 billion to be used to help hospitals, critical care facilities and other healthcare providers fight the COVID-19 virus.

The program is a taxable grant of up to 2% of a dentist’s gross revenues based on the most recent business tax return files. As many dentists and professional advisors reviewed this program, there were concerns about many of the terms and conditions that came with accepting these funds.

It’s important to understand how this grant may apply to your dental organization.

Confusion Over Balanced Billing Terms and Conditions
The biggest concern came from the following terms and conditions:

“The Secretary has concluded that the COVID-19 public health emergency has caused many healthcare providers to have capacity constraints. As a result, patients that would ordinarily be able to choose to receive all care from in-network healthcare providers may no longer be able to receive such care in-network. Accordingly, for all care for a presumptive or actual case of COVID-19, Recipient certifies that it will not seek to collect from the patient out-of-pocket expenses in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network Recipient.”

We believe this item in the Terms and Conditions was intended for a COVID-19 patient who, for example, was taken to a hospital whose ICU was full (and that hospital was an in-network provider of that patient’s insurance) and the patient had to be sent to another hospital that was not an in-network provider to that patient. In that case, the hospital that this patient was sent to would have to honor the patient’s in-network fees charged by that patient’s in-network hospital.

However, by reading the above paragraph, one could infer that if a dentist were to see a patient who has a “presumptive or actual” case of COVID-19 and that dentist was not contracted with the patient’s insurance company, that dentist would have to honor the patient’s in-network fees.

American Dental Association and HHS Seek to Provide Clarification
The American Dental Association started working directly with HHS on this issue. On July 22, the HHS issued a Frequently Asked Question response.

“The prohibition on balance billing applies to "all care for a presumptive or actual case of COVID-19." A presumptive case of COVID-19 is a case where a patient's medical record documentation supports a diagnosis of COVID-19, even if the patient does not have a positive in vitro diagnostic test result in his or her medical record. Dental providers who are not caring for patients with presumptive or actual cases of COVID-19 would not be subject to this provision.”

As virtually all dentists would not be providing patient care for patients who have presumptive or actual cases of COVID-19, this FAQ appears to remove dentists from having to adhere to this balanced billing issue if they accepted this grant money.

We would strongly urge any dentists to review the terms and conditions of this grant program before accepting this grant.

Relief provisions are needed by many. However, it’s important to make sure you understand the terms and conditions of these programs.

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