has been developed, it’s important to inform, educate and train the team on presenting and adhering to the financial policy. The financial information should be presented to the patient prior to the start of extensive and expensive treatment. It is also advisable to have the patient sign the financial policy form and to keep that document on file.
Once the policy has been developed, it’s important to inform, educate and train the team on presenting and adhering to the financial policy.
More information about refunds is available in the “Managing Patients” module of the ADA’s Guidelines for Practice Success™; please see the “Refunds and Discounts” article in the Patient Relations section of that module.
Resources:
• Sample Financial Policy Statement, p.6
• “Refunds and Discounts,” ADA GPSTM on “Managing Patients,” Patient Relations https://success.ada.org/en/practice/guidelines-for-practice-success/managing-patients-patient-relations/refunds-and-discounts
SAMPLE FINANCIAL POLICY STATEMENT
NOTE: This form may or may not satisfy applicable state law. It is imperative that parties relying on this form consult with their legal counsel to modify this form as necessary to comply with applicable law.
Payment for services, including deductibles and copayments, are due at the time of the service unless other arrangements have been made prior to treatment. Payments may be made using cash, check, or credit cards. Any arrangements for third-party financing must be made before starting treatment.
[Practice name] accepts most dental benefit plans. We are happy to submit the claims necessary to see that you receive your benefits. The dental benefit contract is an agreement between you and the dental benefit company. You are ultimately responsible for all charges. We cannot guarantee that any coverage estimated by your plan will be paid once a claim is filed.
In order to maximize your benefits and because plans differ from carrier to carrier, and from policy to policy, our office may refer you to your carrier or your employer’s benefits coordinator for assistance in understanding your plan. Please note that your dental plan is intended to cover some but not all dental care costs, and not all services are covered by your plan. You are responsible for payment of all services regardless of the payable benefit.
Checks that are returned to our office from your financial institution are subject to a $25 returned check fee. This fee covers the processing fees that are charged to our office. We would be happy to discuss our charges and how they relate to your particular situation.
Please indicate your understanding and acceptance of these financial policies by signing below.
| Patient’s name | Date | |
| Patient, guardian or guarantor signature | Date | |
| Witness name | Date |
© ADA 2015. Reproduction of this material by ADA member dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is educational only, does not constitute legal advice, and may not satisfy applicable state law. Changes in applicable laws or regulations may require revision. Contact a qualified lawyer or professional for legal or professional advice.
Patient Direct Pay Practices
Some dental practices are essentially all-cash operations, meaning that no outside or third-party method of payment, such as assignment of payment to the patient through a third-party benefit administrator, is accepted. Patients who have some type of dental benefits are responsible for filing claims on their own in order to receive reimbursement for the cost of dental care received. These patients may have a Health Savings Account (HSA) or Flexible Spending Account (FSA) which allows them to allocate pre-tax dollars to pay for certain healthcare expenses. Patients with these types of accounts typically pay for treatment directly and request documentation that they can submit in order to be reimbursed from the account. It is up to the patient to confirm that the care provided qualifies for reimbursement under the provisions of the Internal Revenue Service (IRS).
While every practice should follow the appropriate financial protocols, dentists who operate all-cash practices must make certain that their accounting procedures are well-documented, double-checked and beyond reproach. Not only is this a financial best practice, it’s also an effective way to protect your practice from possible embezzlement; all-cash practices sometimes lack the documentation and paper trail that’s created when claims are channeled through third-party payment mechanisms. This paper trail offers a certain, although limited, amount of protection against embezzlement.
While every practice should follow the appropriate financial protocols, dentists who operate all-cash practices must make certain that their accounting procedures are well-documented, double-checked and beyond reproach.
Most practices that accept cash payments request — and receive — payment in full at the time of treatment. This protocol often reduces the number of cancelled appointments since patients are already financially committed, recognize the benefits of their care, and recognize the link between their investment and their treatment.
Remember, cash in hand is ideal, but if there is recurring billing you should have a protocol in place that tracks collections daily, weekly and monthly, no exceptions. There are software programs today that can do that for you, but it’s important to understand how the software works so you can be certain that the proper accounting practices are being followed and that what you see in the books matches what your financial person tells you.
Consider offering a cash payment plan to patients who need extensive treatment and who have consistently paid their bills on time. This arrangement allows credit-worthy patients to pay for a portion of their dental work up front as a down payment; the typical amount is generally one-third to one-half of the total cost. It also ensures you can cover any fixed costs, such as lab bills and standard overhead, while simultaneously offering reliable patients a little latitude in paying for treatment. Under this arrangement, the patient makes several payments of a fixed amount on a regular schedule.
Consider offering a cash payment plan to patients who need extensive treatment and who have consistently paid their bills on time.
Discounts
Patients who pay up front occasionally expect a cash discount and many dentists are willing to extend that courtesy if the payment is made by cash or personal check. Carefully consider the loss of income that results from extending a courtesy for payments made by debit or charge card since the practice pays a processing fee to a third party. Dental practices that offer different discounts to different patients put themselves at higher risk for theft, fraud and embezzlement. This is because fraud can easily occur when the same person accepts and processes payments;
