Most of our federal employees have plans the require that I send our claims first to their medical insurance and then to their secondary plan. Typically, the medical insurance pays for only preventative and diagnostic; my problem comes when I'm estimating for this type of patient. SoftDent won't adjust the network adjustment when applicable, so the patient portion has that showing on their estimate.
I think it has to do with the primary insurance having 0% all the categories except preventative and diagnostic. I'm stumped. Anyone out there experience the same thing?
Softdent will not configure the Secondary's allowable ie, adjustment due to the fact that SD(and most other PMS) configure to whichever allowable is entered under the Primary plan. Therefore, if there is not an adjustment on the primary plan, SD will not configure an adjustment at all.
In this situation, I apply an adjustment to the tx plan based upon the secondary allowable. I certainly hope that SD can fix this in future.
TIP: Save the FEHB plan brochure as an EOB in the account and pt doc tree. This Brochure of allowances can be used as your Primary EOB in event of non-covered services, therefore, saving time waiting on a definite primary denial.
I have spoken at length about COB with Jeremy Uriz. I feel that SD/ Carestream is the most reliable PMS when it comes to managing a dental practice AR. A large component to a dental practice success stems from the reliability of PMS tx plan and ledger calculations, as they are an enormous contributor to the success of the patient-office financial relationship. After working with many offices who utilize Dentrix, Eaglesoft, MacPractice, and OPEN, I can tell you that NONE of them are engineered to COB correctly. I can also tell you that COB is an increasing frustration amongst practice staff. Additionally, poor configuration of COB often costs practices and an ENORMOUS amount of cash flow. If SD can improve their already fantastic PMS to make COB calculation an easier task for staff, I can guarantee that SD could improve sales within the market. Please feel free to contact me, this is a lot to send in one response and there is SOOOO much more SD can do that is detrimental to a practice AR that most practices are simply missing out on. My contact is 757-679-6536. Enjoy my novel!!! HAHHAHA! and please forgive any typos, as I was responding quickly during a workday. 🙂
How does COB come into play?
1.) Few dental staff understand the various types of COB and therefore rely on the PMS to calculate the patient portion (ie money fuel for office)
2.) Proper calculations can improve dental tx acceptance.
3.) Dual coverage is more prevalent than in previous years. Dental coverage is a highly sought after employee benefit, therefore, adults often have dual coverage with a spouse. Dependent children of parents who each carry a dental plan will have dual coverage. ACA rules now allow a dependant to remain on the parental plan up to age 24 or 26, these same dependants can carry dual coverage with their own policies.
Q;) How does SD correct this?
A.) COB types such as non-duplicating, carve-out, maintenance of benefits, are thankfully becoming less utilized. Standard COB Calculation Method is as follows:
Primary payment is subtracted from Secondary Allowable, the remainder would be the estimated Secondary payment as long as the remainder did not exceed the amount Secondary would have paid had they been primary.
Here is the math: 50% coverage service. Dual Contracted PPO
Dr. FEE: Prime Allow: Prime Pay: Second Allow: Second Pay: Second Payment:
1000 500 250 800 400 400
Provider adjustment: 350
Patient owes: 0.00
Per the NAIC a basic rule is followed:
The provider can collect up to their whole fee, so long as the patient has the benefit of the lower allowable. This does NOT mean, as you can see above, that the practice writes off to the lower allowable in all cases. In the instance above, both the patient and practice benefited from dual coverage.
Suggestions for Correction:
1) Allow practice to select which plan to configure adjustment to on the PATIENT tab. This would allow for offices to select the lower allowable between two plans when a patient has dual coverage.
A.) Problems that could arise would be a potential over adjustment calculation. This would not be an issue for practices that do not post allowed amounts on ledgers upon posting, as SD simply calculates and does not post the adjustment. Perhaps advising offices to turn off the ability to "post write off at time of service" within the Plan window.
3.) Remove or Correct the COB button on the Claim Filing tab: It simply doesn't work at this time, and furthermore would NOT be accurate if SD calculated per plan, this must be done in the patient tab. Why on the patient tab? Because the lower allowable will can vary between Accounts. Example: A dependent child's primary plan will generally be the plan in which is owned by the parent who has the earliest birthday within a 12-month time frame: also know has the birthday rule. Mother (Higher allowable) birthday is Jan 3rd, Father (lower allowable) is August 6th. The mothers' plan would be primary for the child according to the birthday rule. Current adjustment configuration of SD would not compute the patients portion correctly nor would the adjustments be accurate, therefore throwing off the patient balance.
4.) Create an option in SD Insurance Setup Wizard to configure adjustment to other coverage when there is not an adjustment in patients configured plan.
A.) This is important as now more than 40 states have non-covered legislations/ non-capping legislation that protects providers from having to accept allowed amounts for non-covered services of a plan.
B.) Potential problems with this would be staff oversight, improper training, and of course inadequate COB knowledge. However, if this was simply an option within the wizard, a practice would have the option of utilizing this method of benefit calculations. Practices using this feature should, of course, be using their bluebooks and Fee schedules to ensure accuracy and happiness of their SD product.
Here is the link to the National Association of Insurance Commissioners COB model: