Insurance Estimating

[jeanspears]

We are seeing more plans through Delta Dental of Wisconsin that have the "CheckUp Plus" option - which allows for benefits to paid for periodic exams, prophys, x-rays, fluoride, sealants and space maintainers and they are not applied to the patient's annual maximum. Is there anywhere in the insurance estimating section or blue blue  to mark them as exempt from the maximum?  We use the treatment planning section daily when it comes to estimating and quoting patients benefits and out of pocket expenses.  But when the above mentioned services are posted to the ledger and it estimates they will be covered at 100% - it will deduct that amount from the annual maximum that is entered in the blue book thus making the estimating for future treatment inaccurate.  

[sonyap]

I see in 2017 there was discussion about including this in development.  Any updates?

[carolyn621]

Let me clarify my earlier statement that it is unusual for patients to have rollover. Rollover is plan specific and obviously patients who have accepted extensive treatment they will have utilized all their benefits and no rollover will be available.  The rollover is separate from the annual maximum. And each individual's amount will be based on what is "earned".  This is an example of how it reads: 

MaxRollover Summary

Threshold	$500
Maximum Rollover Amount	$250
Rollover Amount if all Benefits Paid In-Network	$350
Maximum Rollover Account Maximum	$1,000
Personal Maximum Rollover Account	$350

This is a sample of the maximum rollover benefits under this plan. It is not an all inclusive list nor is it a guarantee of the amount of benefits payable. All benefits are subject to the patient's eligibility as defined by the plan on the date services are rendered.

This plan has annual maximum of $1000.00.

The following Max Rollover Summary is for a patient who has $1500.00 annual maximum:

MaxRollover Summary

Threshold	$700
Maximum Rollover Amount	$350
Rollover Amount if all Benefits Paid In-Network	0
Maximum Rollover Account Maximum	$1,250
Personal Maximum Rollover Account	0.0

This is a sample of the maximum rollover benefits under this plan. It is not an all inclusive list nor is it a guarantee of the amount of benefits payable. All benefits are subject to the patient's eligibility as defined by the plan on the date services are rendered.

Hope this helps others.

[carolyn621]

We also have found that numerous other insurance companies where preventive benefits are not part of the maximum benefits. In a future update could a check box be included possibly the same as deductible to exclude these procedures from being calculated as part of the maximum used benefits? 

Second request - we also have found (mostly Guardian) some insurance benefits have a rollover feature - this occurs when a patient does not use benefits from the previous benefit period. We haven't mastered how rollover benefits are calculated so we contact the insurance company, either by phone or online, to look up available benefits and use a Yellow Sticky to help us with the available Rollover Benefits. If anyone has a suggestion let me know.

[Anon]

Carolyn,

I second jeanspears‌, the checkbox option to mark a code exempt is a great idea! 

As for the rollover benefits - it sounds as if patients keep their remaining amounts for the previous year. For example, if I start with $1500 but only use $1000 by year's end, the following year I have $2000 in benefits. Is this correct? Also, how many carry-over years are permitted? 

[carolyn621]

Jeremy,

From our experience, it is unusual for patient's to have rollover. Although, there usually is a maximum amount that is allowed to rollover - it will be employee specific, usually based on longevity. This is listed usually at the end of the benefit/eligibility page during the online search or on the fax. We call or search online if any rollover is available. Your question "How many carry-over years are permitted?" is a good question to ask when calling for amount available. 

Hope this helps.  

[jeanspears]

I agree - a check box to mark a service exempt from the maximum would be great!   I have also seen the rollover benefits with Guardian.  I put a yellow sticky note on the clipboard as well and then adjust the insurance maximum amount.  But you're right - you can only get that info by calling or going online to check the patient's benefits.  

[carolyn621]

Jean,

Like you we attach a sticky for the rollover amount. We created (not original idea to us because we used Trojan in the past for insurance eligibility and found we could obtain the same info faster and with better clarification - that was our experience and others may have a better experience than we had) so we have about Yellow Stickies for all the frequencies and limitations on the plan.  We set it up to be the same for all plans this allows for every staff member, clinical and administration to find the information without leaving asking someone else for it.  It takes time to develop and we have found it to be most helpful and people just have to utilize it. 

[jeanspears]

Carol - 

Great minds think alike  I also use stickies on each employer plan for frequency limits, missing tooth clause, if plans start other than January 1st, or for exclusions.  I date the note and try to update them yearly.  It is tedious to set up initially but now that we've been doing it for the past 10 years or so - it's not so bad to update.  The notes are set up to pop us when making appointments or viewing treatment plans - so if a plan allows recalls 1/6 months - we don't schedule before the 6 month date.  I'm glad I took the time to set it up that way - like you said, any employee can look it up easily.  As for the rollover benefits - I have honestly only seen it with Guardian Insurance employees.  I don't know if there's a maximum amount they can rollover but it does change from year to year depending on their treatment and amount of benefits they used for the year.

[Anon]

Thank you for your inquiry jeanspears‌, 

Currently there is no way to setup estimating to accommodate this setup. Any insurance payment used to clear a claim will reduce the patient's remaining benefits.

However, there are two ways you could address this:

1. Manually edit the patient's remaining benefits. In this case you would enter the IP which would clear the claim and reduce benefits. Afterwards you could go to the patient's remaining benefits and change the Benefit YTD amount:

If the Benefit Recalculator is run before the benefit reset is due your manual edits will be lost. 

2. Clear the claim manually by right clicking on a procedure included in the claim, selecting View/resubmit Primary... and choosing Clear Claim. Once complete, enter the IP without selecting an outstanding claim. The Benefit YTD will not be reduced. Please keep in mind the payment will not be directly associated with the claim either. (For LIA users the payment can still be distributed to the procedures and the Insurance Payment by Procedure report will associate the payment with the procedures.)

[jeanspears]

Thank you Jeremy - I currently do  as you suggest in the first option. I was just wondering if there was a shortcut or step I wasn't finding.  Maybe it's something to consider in a future update? 

[Anon]

jeanspears‌,

We will definitely keep this in mind. I suspect this will become more common in the future.