SoftDent: What to Do When Insurance is not Estimating Correctly

Document created by chriscornett Employee on Jul 14, 2017
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Problem:


What to do when insurance is not estimating correctly

 

Possible Causes:

 

  • Insurance Estimation is not enabled
  • Incorrect ICM selected
  • Incorrect Bluebook entries
  • Incorrect estimation type selected
  • Incorrect Allowance Table entries
  • Coverage Amounts setup incorrectly
  • Used or Unused insurance amounts set in the Guarantor screen
  • Deductibles setup incorrectly
  • Upgradable Procedures are incorrect


Solutions:

 

Enabling Insurance Estimation

There have been many cases where insurance doesn't appear to estimate the insurance estimation checkbox may be unchecked.

 

1. Click System.
2. Select Change System Settings.
3. Select Insurance. Make sure "Enable Insurance Estimation" is on.

 

If this issue is happening for only certain accounts, make sure that the user code "X" is not entered within the account's information. The "X" user code will keep insurance from estimating within an account.


ICM

 

ICM0:

If the practice bills an account the full fee at the time of service and does not accept benefits, select ICM0. The amount due ages immediately from the service date. You can still print insurance forms for your patients as a courtesy, and SOFTDENT Software still calculates the estimated insurance payment for the patient's information.

 

ICM1:

If the practice bills an account only after first billing their insurance company and receiving payment, select ICM1. All patient charges are held current until the insurer has paid. When using ICM1, the account's amount due is always $0 for any charges submitted on an insurance claim. SOFTDENT Software bills the account for charges not covered once you've posted the final insurance payment and marked the claim complete. This amount becomes the amount due and ages from the final insurance payment date.

 

ICM2:

If the practice bills an account their estimated portion (the fee less any estimated insurance payment) at the time of service, select ICM2. The estimated insurance portion is held current, and does not age until you post the final insurance payment and mark the claim complete. The estimated patient portion ages from the service date.

 

Bluebook - Explanation of Fields

 

Insurance Payment:

This amount will always be a dollar amount. And will be the total insurance payment after coverage percentages. The insurance payment cannot be more than the plan fee.

 

Allowed Amount:

The total allowed amount the insurance plan will pay for a certain service.

 

Percent Covered:

The total percentage of the allowed amount that the insurance plan will pay for a certain service, this can also be entered by the "Coverage" tab.

 

Plan Fee:

The total allowed amount the insurance plan will pay for a certain service.

 

Copay:

The amount the patient will pay out of pocket.

 

Fee 0 Amount:

The fee 0 amount as set by the office and is the basis for all bluebook calculations. If fee amounts have been changed recently and this number has not updated, see article # 24020ATL for more information.

 

Date:

The date the Bluebook code was originally entered.

 

Apply to deductible:

Decides whether the specified code will apply to a deductible.

 

Age Limitations:

Adds the ability to set whether patients of a certain age should be eligible to receive a service before or after a certain age.

 

Waiting Period:

The waiting period is a set amount of time a patient must have insurance before a certain procedure can be performed. Basically this keeps patients from buying insurance then immediately having important or costly procedures done and dropping the insurance.

 

Tooth Limitations:

This allows certain procedures to only be covered for certain teeth. In general, certain codes are unnecessary on certain teeth, such as a veneer on a molar.


Bluebook - Estimation Types

 

There are multiple estimation types that affect the way in which the coverage and bluebook amounts are used.

 

Flat Fee:

The insurance plan pays a flat fee, or pre-defined amount for certain types of procedures. There is no maximum allowed amount, nor can Allowance Tables be attached.

 

Method - Flat Fee

 

Total Fee: $63.00 = T
Ins. Pays: $50.00 = I
Pat Pays: $13.00 = P

 

P = T - I

 

Percentage:

The insurance plan pays a percentage of an allowed amount. The patient pays any amount in excess of the allowed amount.

 

Method - Class%

 

Total Fee: $63.00 = T
Allowed Amount: $50.00 = A
Percent Covered: 50% = C
Ins. Pays: $25.00 = I
Pat Pays: $38.00 = P

 

(A x C) = I

 

P = T - I

 

DMO/Capitation:

The insurance plan pays a flat amount or "plan fee" and the patient pays the remaining amount. There is no write-off involved.

Offices generally receive a monthly insurance plan check regardless of the amount of patients seen under a certain company. These checks are entered in the "Transactions" option of the insurance plan. Allowance tables cannot be added to this type of insurance plan. Generally DMO/Capitation plans go by overall coverage amounts as opposed to individual bluebook entries.

 

Method - Cap.

 

Total Fee: $63.00 = T
Plan Fee: $50.00 = F
Ins. Pays: $40.00 = I
Pat Pays: $10.00 = P

 

P = F - I

 

Percentage PPO%:

The insurance plan will pay a percentage of an allowed amount, the patient will pay the remainder of the allowed amount, and the rest will be written off.

Insurance companies send offices a maximum amount they will pay for certain procedures. The office should be entering these amounts in to an Allowance Table and then setting the correct coverage amounts in the individual insurance plans. This will keep the office from having to re-enter the allowed amounts multiple times on each separate insurance plan. Write-offs can be automatically posted, but are generally posted manually once the check is received. As long as the allowance table and insurance coverage percentages are correct, using Automatic Write-off is flawless.

 

Method - Class%

 

Total Fee: $63.00 = T
Allowed Amount: $50.00 = A
Percent Covered: %80 = C
Ins. Pays: $40.00 = I
Pat Pays: $10.00 = P
Write-off: $13.00 = W

 

(A x C) = I

 

P = A - I

 

W = T - A

 

Flat Fee PPO:

Flat fee PPO plans pay a flat rate for specified procedures.

To estimate insurance payments for flat fee PPO plans, set up accurate payment values in the bluebook or allowance table for all procedures. If there is no bluebook entry for the flat fee PPO insurance plan, the percentages specified on the Coverage tab of the Insurance plan window are used. Specify whether a deductible applies to each procedural class when entering dental PPO plans.

 

Method - Flat Fee

 

Total Fee: $63.00 = T
Allowed Amount: $50.00 = A
Ins. Pays: $40.00 = I
Pat Pays: $10.00 = P

Write-off: $13.00 = W

 

P = A - I

 

W = T - A

 

Flat Medicare:

If the insurance plan pays a flat fee for procedural costs based upon the Medicare plan's allowed amounts, select Flat Medicare.

 

Method - Flat Fee

 

Total Fee: $63.00 = T
Allowed Amount: $50.00 = A
Ins. Pays: $40.00 = I
Pat Pays: $10.00 = P
Write-off: $13.00 = W

 

P = A - I

 

W = T - A

 

Percentage (%) Medicare:

If the insurance plan pays a percentage of the procedural costs based upon the Medicare plan's allowed amounts, select % Medicare.

 

Method - Class%

 

Total Fee: $63.00 = T
Allowed Amount: $50.00 = A
Percent Covered: %80 = C
Ins. Pays: $40.00 = I
Pat Pays: $10.00 = P
Write-off: $13.00 = W

 

(A x C) = I

 

P = A - I

 

W = T - A

 

Medicaid:

This estimation type is used in conjunction with most Medicaid plans and changing to this estimation type will affect certain provider or patient IDs that are printed on insurance forms. It calculates via a set amount for the plan fee with a patient co-pay. There is no write-off associated with Medicaid plans. Generally offices receive a bulk check from the insurance company that can be added in to the plan's transactions. Medicaid plans are rarely (if ever) set as "Benefits to Patient". Medicaid plans can not attach to Allowance Tables.

 

Method - Cap

 

Total Fee: $63.00 = T
Plan Fee: $50.00 = F
Pat Pays: $10.00 = P

 

P = T - F

 

Allowance Tables

 

Allowance tables allow an office to enter in set allowed amounts that can be applied to multiple insurance plans. These allowed amounts automatically fill in the bluebook along once attached to an insurance plan. Allowed amounts pulling from an Allowance Table cannot be edited directly in an insurance plan, they must be edited through the Allowance Tables information. Allowance tables can be a great convenience for an office.

Allowance tables cannot be added to all insurance plans under a certain insurance company at once. However, they can be added through easily by performing the following steps.

 

1. Click List.
2. Select Ins. Co.
3. Highlight the Insurance Company in question.
4. Click Show Ins Plans or press <U> on the keyboard. The list of insurance plans attached to this insurance company will be displayed.
5. Edit the first insurance plan and attach the Allowance Table, then click OK.
6. Instead of closing out of the insurance plan, press <+> on the keyboard or click the [+] icon. This will display the next insurance plan's information while already being on the "Coverage" tab.

 

Coverage Amounts

 

Coverage amounts are either entered as percentages (%) or total co-pay amounts. Coverage amounts are filled in by default when an insurance plan is created, then an office may go in and enter the correct coverage amounts as needed. These coverage amounts affect all codes within their specified ranges.

Most insurance plan types allow for "Ded" (Deductible) to be checked for certain code ranges. This means that codes within the code range will look for a deductible if the patient still owes one.

Medicaid and DMO/Capitation plans can set certain code ranges as "Cov'd" (Covered) by the insurance plan, while others may not. This information depends on the insurance plan.

 

Deductibles

 

Individual or ranges of ADA codes can be set to apply to a deductible via the Bluebook or through the Coverage tab. Deductibles are the amount the patient has to pay out-of-pocket for expenses before the insurance company will cover the remaining costs.

To check if a Deductible is affecting the overall patient portion check the following.

 

1. On the "Coverage" tab on the patient's insurance plan, is "Ded" checked for the code range?
2. The Bluebook entry for the codes involved, is "Apply to Deductible" checked?
3. Edit the transaction, does the line "Deductible" have an amount other than $0.00?
4. Does the patient have a remaining deductible if either of the above three sections are true? Check the patient's "G" or "Guarantors" (not via the account, click Guarantors while in the patient information) screen. If the patient has a deductible, this will increase the patient's portion as opposed to the normal estimated amount.

If the family deductible has been met, the individual patient deductible will not apply.

 

The Guarantor Screen

 

The Guarantor screen is an incredibly useful tool when dealing with Insurance issues regarding single or few patients.

To access the Guarantor screen, enter a patient's information and press G on the keyboard or click [Guarantors]. This can be done from both the patient's main information window and the transactions.

 

Many issues involving insurance not estimating for a patient will be due to the lack of "Unused" benefits. Most insurance plans will default to a $1000 maximum for a year.

Although it is recommended for offices to "Rollover" insurance benefits on a MONTHLY basis most offices do not. There are many cases, where some offices do not roll over the benefits for years, so a patient's benefits may not be renewed for years. These amounts can be manually reset by erasing the "Used" amount or entering the correct "Used" amount for this year.

Make sure to note that the Used + TP amounts can go over the maximum amount allowed in a year by the insurance plan.

 

Using Upgradeable Procedures

 

Upgradeable procedures are only an option in versions 12.5.2 and higher.

The Upgraded Procedure option is only available to plans that are first set as %PPO, Flat Fee PPO, or Medicaid. The patient should be set on Fee Schedule 0, which also means the ADA code must also have a fee entered for that number schedule under the Scheduler/Fees tab. Once those are in place, posting that ADA code will then apply the difference in the Allowed Amount balance, PLUS the write-off to the patient.

To select the "Upgraded Procedure" option performs the following steps:

 

1. Click List and select Ins. Plan.
2. Select insurance plan in question within the insurance plan listing and click Bluebook.
3. Double-click the code in question and select the "Upgraded Procedure" checkbox to add the write-off amount (the difference between the allowed amount and the fee) to the "Pat. Pays" amount.
4. Click OK to save the changes.

 

Further Information:

 

Why is there an "Upgraded Procedure" option?

 

Let's say patient X goes in to a practice to get a crown. The patient may have multiple options for the materials used in the crown (gold, silver, etc). However, the code for a crown is just the code and doesn't differ depending on what material is used for the crown. If this is true, the office gets reimbursed the same amount regardless of the type of the material used. All the office can really do is charge more for the code in this case. For percentage and flat fee plans this is not an issue, but for PPO plans the office agrees to accept an allowed amount and write-off the difference. So if the office charges more then they will just have a larger write-off. The "Upgraded Procedure" option is in place to allow the office to roll the write-off amount over on to the patient. In effect, the patient ends up paying more for the more expensive procedure

 

Allowance Table is Higher than UCR Fee's

 

In the event that the allowed amount for a specific code is more than the UCR fee, then the office would need to edit this fee information in the transaction itself for the claim to print out with the correct fee. If not, SoftDent will do all calculations based off of the UCR by default because it is the lower amount. Another option would be to raise their office fee to meet the calculation of the insurance companies.

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