What Dentists Need To Know About Surcharges For Personal Protective Equipment

Jordan Uditsky • July 30, 2020
When dental practices reopened their doors and resumed seeing patients, they did so in a world that, for all of its familiarity, remains dramatically different than it did before the pandemic consumed American life. Among the myriad new issues that practices needed to confront was the imperative of ensuring the health and safety of their patients and staff. But doing so requires more than modified protocols and procedures. It involves a significant investment in the resources necessary for infection prevention and control, including personal protective equipment (PPE).

While dentists and technicians already incurred significant costs in safety gear pre-pandemic, it is estimated that PPE costs for dental practices are now ten to thirty times higher than they were a few short (or long) months ago. This compounds the challenges faced by practices already reeling from an extended period of lost revenues.

To deal with these additional costs, many dental practices are adopting an approach taken by other businesses such as restaurants and salons by charging surcharges for the costs of PPE. While there is nothing inherently problematic in such charges, which can range from $10 to $40, the way practices notify patients about them and how they seek reimbursement from insurance carriers can raise some tricky issues.

The ADA’s Guidance on Documenting Surcharges

The American Dental Association (ADA) has firmly supported the decisions of practices to impose a surcharge for PPE if they so choose, though it does not provide fee guidance. The ADA recommends that those practices that do impose a surcharge do so transparently and consistently: “It is always best to inform patients of any additional charges to avoid any surprise bills. Providing a documented financial policy and seeking consent is desirable.”

As to how best to document charges related to PPE, the ADA advises dentists to develop a standard office policy to document the specific PPE that will be used across all patients. Alternatively, the ADA recommends that dentists add a note in the patient’s record to document the details of the PPE uniquely necessary for the visit when charging different fees based on the level of PPE used.

Coding, Billing, and Reimbursement

In its April 2020 Statement on Third Party Payer Reimbursement for PPE, the ADA urged third-party benefit programs to either:

• Adjust the maximum allowable fees for all procedures, or
• Allow a standard fee per date of service per patient to accommodate the rising costs of PPE. 

Prior to such adjustments taking effect, the ADA suggests that dental offices use CDT code “D1999 - unspecified preventive procedure, by report” to document and report the use and costs for additional PPE. 

The ADA has also issued extensive guidance for third-party PPE coding and billing. The guidance includes a regularly updated list and outline of the specific policies that various carriers have announced. 

Renegotiating Fee Schedules

The additional costs of practicing during the pandemic era and the need to cover those expenses in ways that minimize the amount passed on to patients may require practices to renegotiate their fee schedules with the dental benefit plans for which they are a participating provider.

Before attempting to renegotiate with a carrier, practice owners should be familiar with and have at the ready a range of facts and figures about their practice they can use to make their case for an adjustment. Regarding coronavirus and PPE-related charges specifically, you should know the added per-patient expense you incur for those expenses. You can break these costs down into added disposable PPE costs per patient, as well as added per-patient estimates to recover engineering controls.

Experienced Dental Practice Counsel During An Unprecedented Time

These are indeed unprecedented times for dentists and dental practices. The challenges of maintaining a viable practice while also bearing the new costs required to ensure patient and staff safety can be overwhelming. That is why it is so critical for dental practice owners to have the business and legal resources they need to help them navigate the uncharted waters of this new era. 

At Grogan, Hesse & Uditsky, P.C., we focus a substantial part of our practice on providing exceptional legal services for dentists and dental practices, as well as for orthodontists, periodontists, endodontists, pediatric dentists, and oral surgeons. We understand the concerns and complexities faced by owners and practitioners as the pandemic remains a dominating presence in their practices. We welcome the opportunity to assist you during these unique and difficult times. 

Please call us at (630) 833-5533 or contact us online to arrange for your free initial consultation.

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By Jordan Uditsky November 19, 2025
Whatever shortcomings and deficiencies there may be in the dynamic between dental practices and insurance companies, their distinct roles in patient care are not among them. While dentists certainly want to maximize reimbursements for the services they provide, they are not beholden to insurers and remain in a position to advocate for their patients and challenge an insurer’s cost-related decisions without fear of retribution. But a recent unprecedented move by Delta Dental in Wisconsin threatens to upend this relationship model and has raised serious concerns among industry groups, patient advocates, and regulators about conflicts of interest, competition, and provider independence. Over the summer, Delta Dental announced that it had acquired Cherry Tree Dental, which owns and operates 31 clinics, 25 of which are in Wisconsin. The American Dental Association (ADA) is among several organizations that have vocally opposed the transaction. As the ADA wrote shortly after the deal was announced: When an insurance company becomes both health care provider and insurance payer, questions arise regarding potential conflict of interest. From a business standpoint, dental insurance companies seek to minimize cost and maximize profit. As a result, patients may find their treatment options limited to what is most cost-effective for the insurer, not necessarily what is most effective for their oral health. The ADA believes that the health interests of patients are best protected when dental practices and other private facilities for the delivery of dental care are owned and controlled by a dentist licensed in the jurisdiction where the practice is located. In November, the ADA filed a letter with the Wisconsin Office of the Commissioner of Insurance expanding on its concerns and opposition, including worries about provider independence in making care decisions: Direct ownership by Delta Dental could compromise dentists’ ability to advocate for patients. In traditional arrangements, dentists can appeal plan decisions regarding patient care or choose to leave a network if plan policies are overly restrictive. However, the ADA warned that when dentists are employed by the payer, challenging cost-related decisions could label them as “problem employees,” potentially discouraging proper patient care. The potentially anti-competitive effects of such arrangements were also raised by the ADA, which noted that “Delta Dental’s acquisition could influence agreements, business practices, and fee schedules between Cherry Tree and other payers, potentially creating unfair competition.” In addition to the ADA, the acquisition has drawn concerns from the Wisconsin Dental Association, the American Economic Liberties Project, and the Alliance of Independent Dentists. The fallout of this acquisition, if consummated, could ripple through other markets, potentially leading to a seismic shift in the provider-insurer landscape. We will continue to monitor developments and provide updates as warranted. We Focus on You So You Can Focus on Your Patients At Grogan Hesse & Uditsky, P.C., we focus a substantial part of our practice on providing exceptional legal services for dentists and dental practices, as well as orthodontists, periodontists, endodontists, pediatric dentists, and oral surgeons. We bring unique insights and deep commitment to protecting the interests of dental professionals and their practices and welcome the opportunity to work with you. Please call us at (630) 833-5533 or contact us online to arrange for your free initial consultation. Jordan Uditsky, an accomplished businessman and seasoned attorney, combines his experience as a legal counselor and successful entrepreneur to advise dentists and other business owners in the Chicago area. Jordan grew up in a dental family, with his father, grandfather, and sister each owning their own dental practices. This blend of legal, business, and personal experience provides Jordan with unique insight into his clients’ needs, concerns, and goals. 
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The associate becomes an owner right away, while the practice owner receives a clean and full payout for the equity sold. However, obtaining the needed financing may be easier said than done for an associate dentist, and a large cash payout may also come with unwanted tax ramifications for the owner. Buy-in documents for a cash purchase should address governance rights, profit distribution, and exit mechanisms. They should also define what happens if an associate departs, how future buyouts are valued, and whether non-compete or non-solicitation covenants apply. Installment Sale An installment sale allows the associate to purchase equity over time, making periodic payments instead of an upfront lump-sum payment. After the practice value is determined, the associate agrees to buy a certain percentage of ownership through regular payments (e.g., monthly or quarterly) over several years. Payments may include interest, and ownership may be transferred incrementally or upon full payment. 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Whether you are the associate or the practice owner in such an anticipated transaction, you should consult with an experienced dental practice attorney to understand your options and determine which structure provides you with the most value. Your discussions with your attorney will likely include some or all of these common dental associate buy-in arrangements: Cash Purchase A cash purchase is the most straightforward buy-in model. With either cash on hand or through financing (the more likely scenario), the associate purchases an agreed-upon percentage of the practice (for example, 25% or 50%) for a lump sum based on the appraised value of the practice. That appraisal will likely use metrics such as collections, earnings before interest and taxes (EBIT), or a percentage of annual gross revenue. The main advantage of a cash purchase is its simplicity and immediacy. The associate becomes an owner right away, while the practice owner receives a clean and full payout for the equity sold. However, obtaining the needed financing may be easier said than done for an associate dentist, and a large cash payout may also come with unwanted tax ramifications for the owner. Buy-in documents for a cash purchase should address governance rights, profit distribution, and exit mechanisms. They should also define what happens if an associate departs, how future buyouts are valued, and whether non-compete or non-solicitation covenants apply. Installment Sale An installment sale allows the associate to purchase equity over time, making periodic payments instead of an upfront lump-sum payment. After the practice value is determined, the associate agrees to buy a certain percentage of ownership through regular payments (e.g., monthly or quarterly) over several years. Payments may include interest, and ownership may be transferred incrementally or upon full payment. This is a good option for associates who do not have the means for a full cash buy-in immediately. For owners, this arrangement provides a steady income stream – so long as the associate does not leave before completing payments. That is why the documentation should clearly outline the timing of ownership right transfers and provide robust default remedies, such as forfeiture of prior payments or reversion of ownership interests. Sweat Equity In a sweat equity buy-in, the associate essentially cashes in their years of service, earning ownership over time based on their contribution to the practice’s growth or profitability rather than through an immediate cash investment. In a typical sweat equity arrangement, the associate receives equity credits or options tied to measurable performance benchmarks, such as production levels, collections, or tenure. Once those targets are met, a portion of ownership is granted or sold at a reduced price. This structure enables talented but liquidity-challenged associates to become owners without initial financial strain. It also incentivizes them to grow the practice and stay long-term. Shadow Account (a/k/a Phantom Equity) As I discussed in detail in this post , a shadow account (also known as a phantom equity plan) is an increasingly popular buy-in model, especially when the owner is not yet ready to transfer real equity but wants to reward the associate as if they were an owner. In this model, the associate receives the right to cash payments equal to the value of the shares at a specified later date or distribution event. That value can be established through an appraisal or an agreed-upon formula. The selected events that give an associate a right to a payout can include such things as achieving performance goals, termination, or retirement. There are two types of shadow account/phantom stock plans. In an "appreciation only” plan, the cash payout upon vesting does not include the value of the underlying shares, only the increase in value of that stock since it was granted. In a “full value” plan, the practice pays both the underlying value of the stock and the amount the stock has appreciated while held by the associate. Like actual stock, phantom stock has a defined value and tracks the practice’s performance, but an associate holding phantom stock typically does not have either minority shareholder rights or voting rights in the practice. This makes phantom stock plans attractive for owners who want to provide associates with a sense of equity ownership without giving up any actual control. The practice has broad discretion and flexibility in designing the plan, including valuation formulas and vesting conditions, and the administrative burdens are less than for traditional stock option plans. As noted, the “best” buy-in structure depends on the unique goals of both parties. No matter which model is ultimately adopted, well-crafted documentation, preceded by careful consideration and consultation with counsel, is essential. That is because these deals do more than just transfer ownership - they can lay the foundation for a stable, profitable partnership that preserves the practice’s legacy and rewards everyone’s investment, financial or otherwise. We Focus on You So You Can Focus on Your Patients At Grogan Hesse & Uditsky, P.C., we focus a substantial part of our practice on providing exceptional legal services for dentists and dental practices, as well as orthodontists, periodontists, endodontists, pediatric dentists, and oral surgeons. We bring unique insights and deep commitment to protecting the interests of dental professionals and their practices and welcome the opportunity to work with you. Please call us at (630) 833-5533 or contact us online to arrange for your free initial consultation. Jordan Uditsky, an accomplished businessman and seasoned attorney, combines his experience as a legal counselor and successful entrepreneur to advise dentists and other business owners in the Chicago area. Jordan grew up in a dental family, with his father, grandfather, and sister each owning their own dental practices. This blend of legal, business, and personal experience provides Jordan with unique insight into his clients’ needs, concerns, and goals.
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