3 tiered insurance schedules

[bgalofredds]

Okay, before I set off on a wild goose chase I would like to ask my SoftDent mentors about the challenge before me.

Here is goes:

We are contracted with an insurance company that has 3 tiers of payment. We are contracted at the highest level, but we are receiving patients in the lower 2 paid tiers.  Do I have to make special blue books with the adjusted payments by insurance relative to our max allowable? Can I copy blue books?

Do I make individual allowance tables for each tier?

Also this plan downgrades to amalgams on posterior teeth. :0/

Any recommendations are gratefully appreciated. Thanks.

[FormerPLM]

Hello Mark,

Thank you for participating in the Community.  I'm going to tag a few people on this and get some feedback.  

Thanks,

Jeff

softdentgirl‌

bert‌

d.canales‌

chriscornett‌

[Anon · Accepted solution]

Good Morning 

Insurance is going to force me  into early retirement lol (just kidding)

I would not use an allowance table for these examples, because you are only contracted for the higher tier, the patient is responsible for the difference.  I would use the estimation type Flat Fee PPO and create your blue book.  You will have more flexibility using the Flat fee PPO 

then you have the ability to copy ble books between plans.

Steps 

Click System 

Click Fees Maintenance 

Click Copy Blue book between plans 

Enter the plan # to copy from & to 

Tweak the new plan 

[danelle_canales]

Nice explanation softdentgirl, and I agree.  

bgalofredds, I also would not create additional allowance tables, because they should only show the rate/fee you are contracted to use with the insurance company, and you have indicated that's the fee at the highest tier.  Additionally, to estimate downgrades, have you considered creating additional ADA codes to be used when the downgrade applies for patients using these plans? 

Steps:

1) Under List > ADA, create modified ADA codes with your regular office fee to be used specifically for posterior composites that will be downgraded.  

Ex:  2391.1 -  1 Surface Posterior Composite, 2392.1 - 2 surface Posterior Composite, etc.  You can do this for Crowns, Pontics/Bridges also if downgrades also apply.  

2) Enter these codes into your allowance table. 

3) Enter these codes into your bluebooks as well, setting the coverage amount to that of an amalgam - this will make the remainder between your fee and the write off patient share. 

The claim form will go out correctly showing the original code sans modifier (ex 2391) for your regular office fee, when the EOB comes back with the amalgam downgrade, you will have already estimated the patient portion using the modified codes. Not sure how many patient's this effects, but you probably want to create a team talk to remind you to use these codes when you schedule, treatment plan, and checkout these patients.  

Hope this helps! 

Danelle 

[mdunham]

We have several plans that do this.  Keep an eye on them!   

If you are only held to the higher schedules allowable  proceed with the following:

1.)Add the Allowance table to the Insurance Plan.  

2.) Bluebook will be created.     In the bluebook DO NOT CHANGE THE PAYMENT SECTION TO REFLECT THE ACTUAL  PAYMENT AS IT WILL CHANGE YOUR ALLOWED AMOUNT, ie your adjustment will be wrong on tx plans and ledger.     

         Simply go to the percentage box on the tx item within the bluebook and change the percentage to come close to the payment from the plan.   Doing this keeps your allowed and adjustment amounts correct.  The patients portion may be off a tad here or there, but you are giving an "estimate".    Let me know if you need further help.