How to fix wrong expected insurance and patient out of pocket from Bluebook?

[dental3208]

Our Bluebook estimations are incorrect on estimating the two different portions. I know that updating it takes time and we are updating it through our posting insurance payments window. I have also discovered that each default plan is set to 'percentage' but we are a PPO office. So I have been changing that slot as well (changing it to %PPO) and adding in the correct percentages covered by each plan from the e-Verify feature we just got. But I am now confused because it seems like not all of the plans are %PPO. How do I tell the difference between Flat-Fee PPO fees & Percentage PPO plan fees? We want to get this working so we can tell the patient their estimated oop and to schedule at time of diagnosis and cut the middle of waiting for pre-auths for simple procedures. 

thanks!! 

[bgalofredds]

When I went to the Global Oral Health Conference I was taught how to handle the downgrades to Amalgam on Posterior composites. A super shout out to Wendy Potts! The issue is that I need to present the upcharge from the plans amalgam rate to our  composite rate so the patient is properly prepared for the difference. This could be from $25 - $45 per tooth.

I made a separate allowance table with the Insurance Co and downgrade (i.e. Delta PPO downgrade).

You can copy the current allowance table to save time; Delete the Posterior Composite codes (i. e. D2391, D2392, D2393, D2394). You now have a downgrade template for an insurance plan that requires you to add each of these codes separately. Note: these code values will change depending on the % reimbursement for each plan.

Now the idea is that your allowed rate is going to be the reimbursement amount for the composite rate and the Percent  Covered" will be the percentage that equals the amalgam reimbursement amount. With this formula Softdent calculates the difference between the amalgam and composite as the out of pocket expense for the patient.

In the above example for D2391, for a value of $95 for a D2391 composite; at 62% the insurance payment is $58.90 which is close to the insurance payment for an amalgam at 80% of $59.20. It's not exact, but it close enough that it negligible for estimation purposes. I made an excel spreadsheet with all the information I need for each of the percentages of reimbursement. Now it only takes a few minutes to update a plan and I find its worth the initial work for the results.

I refer to this spreadsheet to make it easier and I have it for each of our in-network insurance plans. I hope this helps.

[mdunham]

I stumbled upon this again and I embarrassingly did not make this additional point.    The scenario you propose will only work for Plans that universally downgrade between Molar and Premolar.     

Many plans downgrade ONLY on Molars.    Therefore your alternate allowance table would only be correct a portion of the time.        Modifier codes entered into allowance table at the same allowance as a general code is the only way I have found to be near precise.  

[mdunham]

Why would you need a separate fee schedule if you are using Locator Codes?   

I use 2391 ( Molar 1 surface Composite) and then 2391.2 ( Premolar 1 Surface Composite)  Both codes are entered into a single fee schedule and then of course populated in bluebooks.  When adding tx to the ledger or tx plan, use the correct code by tooth location and your estimates will work.   No separate fee schedules required.    

The same system of Locator Codes are used for All Porcelain Crowns, Pontics, etc of any type.  Equally, I enter 4910 (first series) 4910.2 (second series)  4910.3 (third series and 4910.4 (fourth series)  to allow proper OOP in Ledger.      This helps keeps the little bills to a minimum and will keep your AR low as well. 

[bgalofredds]

I think you are onto something, Ms. Dunham. I'm still not understanding it fully. When you come to a composite locator code (like 2391) that will be paid as an amalgam. How are you filling out the code so the difference between the amalgam and composite is billed to the patient? Thanks for your input. 

[mdunham]

Most if not all plans now perform a downgrade of alternate materials when a composite or all porcelain material is used on molars, and very often premolars as well.  

To easily create a pathway to record these instances per plan, simply create modifier codes as suggested in my earlier post.  Add these codes into any applicable fee schedules., once applied in a fee schedule it should automatically appear within your bluebooks for editing.  

Modifier codes placed in a Fee Schedule should have the same Allowance as its counterpart code.  As contractual adjustments should only be to the procedure performed, not to the alternate. 

After the new fee schedule is attached to the Plan, you can easily distinguish the difference in reimbursement levels by tooth LOCATION.  Which of course allows for more accurate treatment planning and ledger details.  

I hope this helps.

[bryandental]

As repeatedly noted; there should be an easier way to have the correct insurance estimates than the way mdunham has given example of.  When you have hundreds of plans you are working with this way just not acceptable. There needs to be an update to change the entire structure of the insurance in softdent.  

[mdunham]

When you add a payment it can change your allowed amount which effects your writeoff column.   You can change the percentage slightly to reflect a payment that would be closest to the actual payment from the plan.    OR, you can use Flat FEE ppo for all PPO plans, then you would be able to change your payment amount and NOT affect your allowed amount.  I am new to trying this and have good luck so far.   

Danelle, how would you recommend us to add in our plans if we need adjustments and payments to be accurate?   Would you warn against entering as a Flat Fee PPO when the plan is a PPO % payor?

Thanks, 

Melissa

[danelle_canales · Accepted solution]

Hi Greta! 

Sounds like you are on the right track - updating your Insurance Plans/Allowance Tables/Bluebooks is the correct way to make sure SoftDent is able to estimate a patient's Out of Pocket portion/insurance share correctly so that you do not need to wait on pre-authorizations for routine estimates.  

As far as your Bluebooks being incorrect, again you were right on the money when you said it takes time and continued effort to get and keep them updated and an important step is making sure you are posting money through the payments window.  Another important step is verifying the setup of each insurance plan as patients come into the practice and benefits are verified. 

• %PPO should be selected as the estimation type when you are in-network with the carrier, and they have agreed to pay a percentage of their allowed or contracted amounts (these numbers should be entered into SoftDent as an Allowance Table). 
• Flat Fee PPO should be selected as the estimation type when you are in-network with the carrier and they have agreed to pay flat amounts (in varying percentages) of their allowed or contracted amounts.  

I am glad that you are trying eVerify - our eServices are great, and this can be very helpful in determining which estimation type is appropriate and what numbers should be entered to achieve correct estimates. 

In your case I recommend two things: 

1. Stick with it.  As you update insurance plans make a small indicator next to the name (perhaps an asterisk) to let you know this plan has been updated and is correct.  As payments come back (especially for those updated plans) make sure you are updating Bluebook numbers - there is a prompt that can be turned on so you are asked to update the Bluebook after each insurance payment. 
2. If you are still confused, consider purchasing some one-on-one training.  I know up front one-on-one training rates can seem a little steep, but I guarantee they are worthy investment in your practice and can clear up a lot of confusion in a short period of time.  It may be very helpful to get a trainer to look at your current setup and make recommendations, and also to walk you through some of the things discussed here step by step.  

Best of luck, I know you will do great and looking forward to hearing your success story!  

Danelle

[dental3208]

Hi Danelle! 

Thank you so much for your thorough response! I think that most, and if not all, of our contracted plans are %PPO and changing to that estimation type has helped when posting those payments through the updating the Bluebook window & prompt. 

For clarification - the Flat Fee PPO flat amounts (in varying percentages) does that refer to the 100, 80, 50 etc percentages in the coverage tab? Is there some sort of a general outline of carriers that are Flat Fee PPO vs % PPO (Delta vs. Guardian)? Or is it plan to plan?

It can get confusing when the gray screen pops up with the current and new bluebook entry and they're wrong again, so I have to re-do the payment, allowed amount etc. But it is very satisfying when it does populate with the correct write-off and insurance payment! 

I know I've seen some info on when insurance companies give a substitute for an allowance like the amalgam instead of composite posterior fillings - which we do a lot of. How can we make sure that those estimations are going to be correct. The amalgam codes are not in our Fee0 office schedule, so they are not in any allowance tables. 

Marking the names is a great idea! I will establish that as a procedure now to make sure we are on top of adding the allowance tables and making the correct adjustments to their coverage tab so there isn't any confusion. I am also going to look into the one-on-one training, too. I think it will be a great investment! 

[mdunham]

 Here is an efficient way of calculating downgrades.  This makes our ledgers and Tx plans PERFECT, every time!    Your claims will not be effected as suffix number will not print on the claim form, only the ADA number.  Equally, your reports will be correct as the point codes are included in the whole ADA code for calculations, etc.   

To correctly estimate downgrades.   

First:   Enter ADA code list and create  the following codes:

 2391.1 Premolar 1 Surface Posterior Composite

2392.1 Premolar 2 surface Posterior Composite

2393.1 Premolar 3 surface Posterior Composite

2394.1 Premolar 4 surface Posterior Composite

2740.1 Anterior All Porcelain Crown

2740.2 Premolar All Porcelain Crown

2740.3 Molar All Porcelain Crown

(do this for Porcelain fused to metal crowns if you see a trend in downgrades with these as well.)

  Enter the same also for the 6740 and corresponding Pontic Codes as well.     I enter Anterior, premolar and Molars as companies pay differently on these within the same plan.

Second:

Mark Inactive the Original code. Use your "locator code"  instead.  (Locator Code is my term for coding by tooth location.) 

Third:

Now Enter all of these codes into your allowance tables using the same FEE as your general codes.   

Fourth:   When you enter your blue-books entries, be sure to create these codes.   Now your treatment plans should be correct!     See my entry below, which is only showing fillings of course.

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