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Accuracy of Third Party Payer Insurance Productions & Adjustment Reports

Accuracy of Third Party Payer Insurance Productions & Adjustment Reports

Most SD users are frustrated with the inaccurate and tedious Insurance collection and Adjustment Reports.  My suggestion is to either create a new set of reports/ or correct the current "Contractual Insurance Company Production" (and the complimentary adjustment report) to pull the report data from the ALLOWANCE table to which a PLAN is attached.  

 The reason I suggest such a report is the following: 

1.) Company Network Products are often leased to TPP(third-party payers) and would allow an office to view their production/adjustments for contracted TPP's.   It is currently difficult and almost impossible to perform this within SD. 

2.) Companies often have different claims address and Company names.  Example: Delta Dental as a company will have different addresses for commercial products written within states, ie, Delta Dental of MI, CA, etc.   My suggestion would allow all of those plans to be included on one report because the Delta Dental Allowance table would be attached to those plans. 

3.) Company Network Products can switch or drop participation with a TPP.  Because these network arrangements are not COMPANY wide.  Example:  United Concordia Advantage plan drops participation with Careington TPP and elects to join Connection TPP.    If a DDS is not participating with UCCI PPO, but has an agreement with Connection, the DDS is now "in network via Connection" for pts with UCCI Advantage.    Currently, SD only allows for the PROD/ADJ data to be pulled via Company/ or Plan.  A report, per Company, ie in this case; Connection, could not be used, because the claims for TPP's are not handled by the Contracting Company, ie, Connection/Careington /DHA/ Principal/ etc. Claims are handled by the Company in which has the leased network, ie; Cigna would handle claims for Cigna Advantage and not the TPP. 

4.) Cross-Networking contract arrangements:  Very often DDS are contracted with multiple TPP's and negotiations upon signing allow for a provider to collect the highest of their schedules between cross-networked products.    Example: DDS has an agreement with Careington and Connection wherein the DDS has a higher allowance with Connection.  Cigna Advantage is cross-networked with Careington and Connection,  the provider will use the Connection Schedule for Cigna Advantage products due to his higher allowance negotiations.    If Cigna Advantage pulls participation from Connection now the Careington Schedule would apply.  

Questions to ponder:

 1.) When pulling report data based upon allowance table added to plan. How would this effect report data when an allowance table is changed during a reporting time frame?   

 

  

3 Comments
CS Dental Employee
CS Dental Employee

Tagging @tyson_edwards for review.

@mdunham , are TPP's the same as Silent PPO's?

Thank you,

Jeremy

mdunham
Premolar III

Yes, you got it, Jeremy.  The "nicknames" are many for  Third Party Payer Agreements.  Examples are:  Leased Agreement Networks, Silent PPO, Leased Partners, Umbrella Networks, I am sure I am missing a few as well.   There are two types. 

Direct PPO has a Leased Agreement /TPP:  ExampleProvider has a direct contract with Principal, yes is also amended into accepting pts on their leased networks Ameritas, Reliance, and Reliance Standard. 

Contracted TPP: Example: A copy in which is a Third Party Administrator to many leased PPO products.  For example, Careington, Connection, Sunlife/DHA, all lease PRODUCTS of National PPOs.     

A provider could not be in network with MetLife, yet be considered an in-network provider for patients under the PDP Plus Network which is leased by his contracted TPP Careington. 

Therefore, you see it would be beneficial for providers to have the option to run AR and Production reports by Allowance Table, or rather, any plan with the Allowance Table attached to it.   SD would also have to be careful to make it so that reports reflect accurate information should the plan switch Allowance Tables during a time frame.  

mdunham
Premolar III

Ps. the selling point to this is that Eaglesoft, Dentrix, nor Open I believe allow for providers to obtain this info by Contracted Agreement.  Selling Point as it allows for providers to have real-time reports.  Many providers do NOT know their leased agreements, IF they could run reports, it could help providers determine which plans to stay, depart, or negotiate with.   Currently, I have a "workaround" for SD offices that I set up to assist them with obtaining this information on all reports.  Correct information is imperative when determining the following: Contract Negotiations, Marketing, Participation Status, Selling Practices, Purchasing Practices and hiring Associates.