Insurance Estimating - what needs to change to keep up with the Joneses?

[danelle_canales]

In another thread, there was mention of updating insurance estimation - it is my understanding with all the new plan designs out there there may be need for some different calculation methods going forward.  

@suzanne, and others, what do you know about insurance estimates/the changes you are seeing, and what you need the software to do to make you the most successful? 

[debi_peterson]

I agree that this needs everyone's eyeballs. Insurance is changing all of the time, and our estimating needs to be flexible enough to handle those changes.

[danelle_canales]

@Nina-Gilbert, @kevin_moloney, @matt_ackerman many of these things would apply to PW, CMP, and WinOMS too.  

[callton]

Another thing I've encountered with some Delta plans is a fixed co-pay by appointment....If a patient comes in for a preventive/diagnostic appointment, they  pay $65 regardless of whether they just have an exam or have exam, x-rays, and cleaning.  It would be nice to have that estimate correctly, if possible.  I think insurance companies dream up ways to give us nightmares.

[suzanne]

@callton Yes!  We have a section of plans that have a $5 or $10 copay for every visit no matter what procedure is done.  Then they pay their % of the fee schedule, after subtracting the copay to the first procedure on that DOS.

[suzanne]

Since 2018, I've seen a lot of new plan designs that are impossible to track in Softdent currently.  Here are some of the issues:

1. The anniversary date that the Maximum/Deductible turns over is sometimes the Effective Date of when the Subscriber signed up, so it can vary by plan participant.  I select the "None/Varies" entry in the InsPlan, but we are still having to manually track these patients' Max/Ded every time they come in.
2. A subsection for Implant codes on the Coverage tab, with a related "lifetime max" checkbox on the Info tab and a field to enter the lifetime max (like the Ortho field).
3. Several plans are now excluding Prev/Diag services from the annual max.  Therefore, in addition to the "waive ded" checkbox, it would be nice to have an "excluded from max" checkbox on the Coverage tab.
4. The FMX frequency limits are anywhere from 1-5 yrs, so allowing users to choose from more than just 2 options would be helpful.  Also, a related checkbox to indicate whether a plan combines the freq limit for pan/FMX would also be helpful.  Since the Patient Dates tab tracks these two procedures independently, it seems logical that they could be independently accounted for in the InsPlan or Bluebook window as well.
5. Quite often we are seeing a separate coverage level for relines/rebases/repairs of Part/Dentures, so a subsection for those codes would be helpful (like the Post subsection).  Also, recements/repairs to crowns/bridges are commonly separated out as well.
6. Within each major prosthetic category, perhaps a Prosthetic Replacement checkbox, similar to the W/P column.  Some InsPlans have a different replacement clause for Crown/Bridge than they do for Part/Dent. However, this would probably be just an "Information Only" type of field since the Prosth Replcmt applies to tooth #s, not by code.
7. Since the 9000 code coverage is so variable among plans, it would be helpful to separate these into "logical" subsections.  Some suggestions: Anesthesia/Med codes, Visit codes (consults, home/hospital, OV), Cleaning codes, TMJ-type codes.
8. We need a way to account for "linked" codes when an InsPlan groups certain codes into the same freq limit, akin to the pan/FMX issue, but perhaps more flexible.  For example, the most common one I'm seeing is the "prophy" code group: 1110, 4346, 4355, 4910.  Some plans state the freq limit applies to ALL codes in that group, while other plans just include 1110/4346/4910, and still other plans only include 1110/4346.  
9. Another group of linked codes are the exams: 120-180/9110/9310/9430.  Again, I've seen all combinations of what falls into the Exam freq limit.  Some examples:  All exams: 2/cal yr;  120/150/180 are 2/cal yr, but 140 is unlimited;  9110: (Prev) Unlimited;  9110: Freq limit w/ exams, but paid at Basic level;  9110: No freq limit, but paid at Major level.
10. Similar to the linked codes above, are plans that allow only 2 fillings per year, regardless of the tooth # or # of surfaces.  For example, only 2 of the following codes are allowed per year: 2140-2335, 2391-2394.  These plans usually have a 2 extraction limit per year as well (7140/7210).  
11. There are also plans that separate their coverage Type by the category of service.  For example, many Individual Plans we are seeing will pay 100% of either our UCR or PPO fee for Prev/Diag, but then pay a flat fee for all other categories.    
12. Since Tiered Plans are becoming more common, we are having to enter 3 separate plans in Softdent to account for the increase in % each year, even though the only thing changing is the Coverage %.  It would be extremely helpful to have the Bluebooks duplicated w/o losing the nuances of each code entry (age/tooth limits), but just having the % changed.  Also, let's say we get an EOB back for a 9110 and adjust the BB to reflect coverage in the Basic category with deductible applied, it would be helpful if the other 2 tiers would also keep the specifics of that code, with just an increase in the % covered.  Since there are so many variables here, an option might be to start with having a separate checkbox on the Info tab to indicate it's a Tiered Plan.  Then on the Coverage tab, perhaps 2 more columns to list the 2nd & 3rd year %s.  To help with the BB continuity, perhaps have a section on the Info tab that lists Prev, Basic, Major and we can fill in the corresponding %s.  Then, for those procedures that deviate from the "major categories %", we can edit the particular code(s) in the BB and select whether the % should follow the Prev/Basic/Major progression of tiered %s.
13. Updating 20 Allowance Tables has been the bane of our practice every year, and of course I can't get it all done within the 1st day of the year.  So allowing us to import an .xls or .csv file of the updated fees would be greatly appreciated and save a lot of headache and extra work of incorrect estimates.
14. And finally....please fix the insurance estimation for downgraded procedure codes.  The "change BB percentage to get it as close as you can" method creates more problems than it solves.  

[Anon]

Yes, I agree, insurance plans are changing daily and we need to keep up with the changes.  Thank for you requests.

Wendy

[mdunham]

I applaud all of these. 

[mdunham]

1.)  As of today, 42 states have adopted  "Non-covered or Fee Capping legislation"  A very easy way for SD to correct some insurance estimation is to AUTO CHECK the Box w/in BB screen to upgrade to practice fee. , ie NO ADJUSTMENT.  

2.)   Allow adjustments on Secondary Plans,  Especially if there is no adjustment to be considered on patients' primary plan, ie, non-covered, Primary plan is non-contracted. etc.  

There is MUCH more that can be done to improve Ins estimation, these two tasks would in the very least provide much relief to users. 

[suzanne]

@mdunham: Related to your suggestion of the "no adjustment" checkbox...
It should be easier to adjust a PPO BB entry to reflect that a procedure isn't covered by a particular plan (cosmetic reasons, etc) but we are still accepting the PPO fee as payment in full. Currently, when adjusting an individual procedure to 0% coverage, it also zeroes out the PPO fee. We have to completely delete the code, then re-enter it in order to pull the PPO fee back over to the individual code and then set the % to 0. Perhaps the checkbox could toggle whether the PPO fee is linked or not.

[mdunham]

The upgrade box would take the pt owes an amount to your fee whether there is an allowance entered or not.    Unfortunately, if you are providing the plan adjustment to non-covered tx as a routine, the only way to do that is as you have stated.  

I agree, there should be an easier way.  Perhaps the wizards at SD could provide an option to mark a BB entry as Non-covered Apply Adjustment.    This would take zero from plan and apply adjustment.   

My suggestion to them was to auto check the upgrade box for all percentages set to 0% in the plan, as most states have protection now.    If they did that and did not incorporate an option to allow adjustment per code, you still would be back to your current workaround option.   

In the perfect world, they will get this working.  Hang in there.  

[danelle_canales]

Awesome information - thank you for writing this up!  

I will sit down and review tomorrow then forward on as user stories to our development team.  

[danelle_canales]

@Anon @Nina-Gilbert  @Anon  - this one needs everyone's eyeballs.