Billing for dentists and orthodontists - what you need to pay attention to

Dental and orthodontic services are a fundamental part of the population's healthcare. Dental cleanings, braces and veneers in particular are popular preventive treatments and instruments for correcting misalignments in children, adolescents and adults. In 2018, the statutory health insurance funds spent around 1.15 billion euros on orthodontic services alone. However, insurance companies do not cover the costs of every measure and treatment. This is because dental and orthodontic treatments must not exceed what is necessary according to SGB V §12.

These restrictions create billing challenges for many physicians. After all, more and more patients want services that are only subsidized by the health insurance fund or that they have to pay for entirely privately. This often complicates the billing process, as different legal bases apply with regard to medical fees. But what are these in concrete terms and how can the costs for self-pay and health insurance services be calculated?

This is how billing according to BEMA works

In principle, services provided by panel doctors ("Kassenleistungen") are billed to the statutory health insurers according to the valuation scale for dental services (BEMA).

The BEMA only lists what the health insurance funds cover in part or in full on the basis of the statutory obligation to pay. In total, dentists bill for over 100 million treatment cases every year!

This is how the BEMA is structured

The BEMA comprises five parts. The third part is particularly relevant for orthodontists.

• Part 1: Conservative and surgical services and X-ray services
• Part 2: Treatment of injuries of the facial skull
• Part 3: Orthodontic treatments
• Part 4: Systematic treatment of periodontal diseases
• Part 5: Dental prosthesis and crowns supply

You can easily access the BEMA online and digitally locate the services you want to bill for using the search function.

Cost calculation according to the BEMA

Each contractual dental service has its own number, service description and evaluation number.

Example: The ,,In-depth examination to determine dental, oral and maxillofacial diseases including consultation" in Part 1 of BEMA has the number 01 and the evaluation number 18.

The assessment number is multiplied by a point value to determine the costs that the statutory health insurance funds reimburse for this service. The point value applies at the state level and differs depending on the health insurance fund. The only exception: The point value for Part 5, the provision of dental prostheses and crowns, is determined at the federal level.

Example: For patients in Berlin who are insured with the AOK, the current number of points for KCH/PAR/KB services is 1.1479. This results in the following cost calculation for the in-depth examination: 18 x 1.1479 = 20.6622 euros.

Patients who are not covered by statutory insurance can, of course, take advantage of the same treatments. However, this is to be billed differently, according to GOZ, as it is paid privately.

This is how billing according to GOZ works

Remuneration for dental and orthodontic services that are not covered by the statutory health insurance funds is governed by the German Scale of Fees for Dentists (GOZ).

This is how the GOZ is structured

The GOZ comprises eleven sections:

1. General dental services
2. Prophylactic services
3. Preservative services
4. Surgical services
5. Services for diseases of the oral mucosa and periodontium
6. Prosthetic services
7. Orthodontic services
8. Insertion of bite blocks and splints
9. Functional analysis and functional therapy services
10. Implantological services
11. Surcharges for certain dental surgical services

Please note that the services under numbers 6100, 6120, 6140, 6150 also include material and laboratory costs for standard materials. Additional costs for materials can also be billed separately if this has been specified accordingly in the written treatment contract with your patients.

You can also view the GOZ online at the German Dental Association and search for specific services for your billing.

Cost calculation according to the GOZ

As in the BEMA, numbers and point values are assigned to the services of the GOZ. The point value is uniform throughout Germany and is 0.0562421.

Example: The "Detailed examination to determine dental, oral and maxillofacial diseases, including periodontal examination and recording of the findings" has the GOZ number 0010 and the number of points 100. For the simple fee rate, this means the following calculation: 100 x 0.0562421 = 5.62 euros.

Unlike BEMA billing, the GOZ also offers the option of applying an increase rate or factor. The higher the increase rate, the higher the costs for the treatment will ultimately be. This reflects the degree of difficulty of the treatment. You can choose from the following rates:

• 1-fold set: easy difficulty
• 2.3-fold set: normal difficulty level
• 3.5-fold set: high level of difficulty

Example: The in-depth examination is to be charged at 2.3 times the rate. This means the following calculation: 100 x 0.0562421 x 2.3 = 12.94 euros.

Important: A single or 2.3-fold increase rate does not require justification. The situation is different for the 3.5-fold rate: Here you should explain to your patients in writing the reasons why you have chosen this assessment basis.

Beware of double billing!

According to the GOZ, certain services may not be billed twice. You can recognize which services these are by certain number combinations. An example of this is the joint billing of 0040 (preparation of a treatment and cost plan for orthodontics) and 0030 (preparation of a treatment and cost plan).

In addition to these, there are many other specifics to billing, which is why many dentists wonder how best to manage the process: bill yourself or have someone bill you?

Your options: Internal or external GOZ billing

After treatment, the bureaucracy of billing for private and self-pay services begins. Depending on the billing model, this can quickly result in a high (additional) time burden for physicians and practice staff.

External billing by service provider

There are many service providers to whom you can outsource some or all of your accounting for a fee. Some providers even assume the risk of non-payment ("true factoring"). Others, on the other hand, do not insure you ("non-genuine factoring").

Attention cost trap: Before you decide on an external service provider, you should compare different providers.

Internal GOZ billing by the practice staff

In principle, dental or orthodontic billing in accordance with GOZ can also be handled internally. You or your practice team can take care of all the accounting steps yourself. However, make sure that you allow enough time for the tasks involved or use digital billing software such as Nelly. Because thanks to Nelly, you save around 90 minutes a day - valuable time that is available to you and your employees for treating patients.

Simple GOZ billing according to with Nelly

Patients simply select the form of payment and let the payment and billing technology take care of the rest - that's how quick and easy automated billing of private or self-pay services works with Nelly. Your additional advantage: No further training is required to use Nelly! We will advise you on your individual case free of charge and without obligation.

Contact Nelly now!

The personal designations used in this article always refer equally to all persons. For the sake of better readability, we do not use the same name twice or in the opposite gender.

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