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Bluebook Workaround for Downgrades

Bluebook Workaround for Downgrades

While tweaking yet another Bluebook yesterday which downgrades posterior composites, I was very frustrated! Once you've established an Allowance Table (even one with alternate codes for downgrades, ie. D2391.1) and properly set up an insurance plan, you cannot go into the Bluebook and change the fees to properly reflect the downgrade. 

I propose the addition of a check box for overriding the percentile/allowable set-up. This would provide a way to enter the precise amount the insurance will pay and the allowable, which is often different from what is in the Allowance Table.

6 Comments
mdunham
Premolar III

When correcting the payment inside the bluebook to reflect what the plan actually paid, do not change the Payment field as this will change your allowable and therefore your adjustment will be incorrect.   Simply change the percentage to get as close as you can to the actual payment from plan.    Sometimes this must be 55% instead of the customary 80% on restorative.   

Also, be sure that your Allowance Table has your contracted rate for that service.  The Allowance table should never have the downgraded treatment allowable as your allowable for that service.    

Lastly, the obvious; be sure that you are posting the correct code for the tooth number-- ie, if 2391.1 is a premolar code in your office, determine if a staff member incorrectly posted a molar tooth number on he premolar code transaction.  

Does this help?  

Feel free to give me a call if you need help, there is generally a very easy explanation.  757-427-7130

bayarea
Canine III

I appreciate the tip. I have tried using a percentage which brings the patient portion close to the correct number, but I'm a stickler. I don't want close; I want the amount that I need. That way I can confidently have anyone use the system, not just the few who fully understand the intricacies of the insurance world to which we are privy. 

CS Dental Employee
CS Dental Employee

I feel in you could override a %PPO plan at the Bluebook level and mark it a Flatt Fee PPO for a single procedure this would allow you to enter the correct amount.  A bonus would be if it was broken down like this (I added a section for the downgraded amount, this way any thing entered in this box would be the patients co-pay)

jesslingle
Canine III

We have had a lot of luck with using the 'upgraded procedure' check box in the blue book.  When in the blue book double click on the specific code.  Check the box for 'upgraded procedure'.  This applies all of the write off to the patient portion.  It does figure the amount correctly- the way that most insurances pay us for downgraded procedures.  Of course there are always outliers but... it is right a lot of the time.

mdunham
Premolar III

Jessica,  that will only truly work for a procedure code in which is not downgraded by the tooths location in mouth, and non-covered services.  Have you created Locator codes or codes that define a tooth by location?  

mdunham
Premolar III

Wendy, that would be great if we could change the configuration per code.  Great idea!