7.4 Fee Estimates, Billing Limits, and Patient Financing

Estimates required before treatment (K1151)

The federal good faith estimate

The No Surprises Act, effective January 1, 2022, requires health care providers, dentists included, to give uninsured or self-pay patients a good faith estimate (GFE) of expected charges. "Self-pay" includes insured patients who choose not to use their coverage.

Care scheduled 0–2 business days ahead does not trigger a GFE. The estimate must be itemized, in writing (paper or electronic as the patient prefers), and list the expected charges for items and services, with service codes, from that provider.

California's patient-credit law

B&P § 654.3 applies whenever the office arranges or establishes third-party credit or a loan, such as a health care credit card, for a patient:

1. Written treatment plan first: each anticipated service and its estimated cost. If the office takes assignment of insurance benefits, show the patient's estimated share. For Medi-Cal patients, disclose whether Medi-Cal covers an alternative medically necessary service. If the office does not take assignment, state that coverage is uncertain and that the patient can check with the plan (§ 654.3(h)).
2. One-page notice in at least 14-point type, signed by the patient. It explains that this is a loan or credit card, not a payment plan with the office; that the patient does not have to apply; that they may have a treatment plan first; and their refund rights (§ 654.3(g)). Patients who communicate primarily in a Medi-Cal threshold language get it in that language (§ 654.3(i)).
3. No early charges: the office may not charge the account more than 30 days before the treatment is provided, except incremental orthodontic fees (§ 654.3(c)).
4. Refunds: refund the lender within 15 business days of the patient's request for any treatment not provided (§ 654.3(f)).
5. No pressure: the office may not fill out the application for the patient, and may not arrange credit while the patient is under general anesthesia, conscious sedation, or nitrous oxide, or while in a treatment area unless the patient agrees (§ 654.3(e), (j)).
6. The office itself may not arrange open-end credit with a deferred-interest provision (§ 654.3(b)).

Limits tied to the estimate (K1152)

The GFE has consequences. If an uninsured or self-pay patient's final bill from a provider is at least $400 more than that provider's GFE, the patient may start the federal patient-provider dispute resolution process within 120 calendar days of receiving the bill. The patient pays a small administrative fee, set at $25 when the process began in 2022. An independent dispute resolution entity then decides what the patient owes. While the dispute is pending, the provider may not send the disputed bill to collections or add late fees. The practical lesson is to build foreseeable add-ons into the estimate and to issue a revised GFE before treatment when the plan changes.

California's credit statute has the same effect for financed care: the patient can get a refund for anything charged but not delivered, and the written plan documents what was quoted.

Other laws on fees (K1153)

The ADA Code's Section 5.B, on representation of fees, forbids misrepresenting fees: no raising a fee because the patient has insurance (overbilling), and no waiving copayments without telling the insurer. Chapter 12 covers these billing ethics.

Worked scenario

A self-pay patient schedules four implants two weeks out. The office emails an itemized GFE of $14,800 the next day. After treatment, the office bills $15,600 because a bone graft was added.

• The GFE was on time: within three business days for care scheduled 10 or more business days ahead.
• The overage is $800, which is at least $400 more than the estimate, so the patient may dispute within 120 days.
• Better practice: discuss the possible graft in advance, include it in the GFE, and document informed consent to the added cost.