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cdasmile
Canine II

Calculating secondary insurance

I wanted to see how other offices deal with this situation. We have patients that have the Federal Blue Cross plan that only has preventive coverage. Secondary is Geha which has Preventive, basic, and major. If your in network how do you get it to calculate correctly with the secondary write off amount? Our treatment plans are not calculating correctly.

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callton
Premolar I

Re: Calculating secondary insurance

Do you have an allowance table for GEHA?  That should help.

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jpisariktnosi
Premolar I

Re: Calculating secondary insurance

We're oral surgery and deal with primary and secondary ALL THE TIME! I created a very complex Excel calculator that has all of our allowables and calculates the primary and secondary payments accordingly. So if you're using a CareStream treatment calculator I can't really help you with specifics.

However, we deal a lot with GEHA and Fed BCBS. The two are very closely linked and GEHA usually knows what BCBS will pay without you even sending them a medical EOB. So for them, I would get your fee allowance schedule from GEHA and use those discounts (for us, it's the Cigna fee schedule). For payment, assume that whatever GEHA says is the benefit (80%, 60%, etc) will be what you will get TOTAL from a combo of the payers. If GEHA says a patient gets 80% coverage on something they allow $100 for, GEHA will pay $80 minus whatever BCBS pays. So the patient owes $20 no matter what BCBS pays. Basically, in this scenario, bc they are linked closely, go with whatever GEHA says and pretend BCBS doesn't exist in your calculations. That should work.

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jpisariktnosi
Premolar I

Re: Calculating secondary insurance

This situation gets a lot more difficult if you're dealing with insurances that aren't linked like BCBS and GEHA. That would be a whole other discussion and is based a lot of the specifics of an individual's policy (is secondary standard or non-duplicating? are the same procedures covered by both plans at the same percentage? does secondary process by line item or claim as a whole? etc etc etc). 

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mdunham
Premolar III

Re: Calculating secondary insurance

Softdent will automatically calculate the adjustment to Primary dental plan.  If there is not an adjustment with primary, ie Federal, you must configure adjustment for the Secondary (Geha).  Hopefully, in future versions of 17, this will be corrected.      If you have Allowance Table added to GEHA plan, you can review the bluebook for your adjustment amount per ADA code.     

We are hoping that in future versions of Softdent that users will have the option to assign adjustment calculation per patient, this would definitely help in your instance referenced and in cases of blended families with multiple ppo's etc.  VOTE on this topic idea.  Let Carestream know we really do need this.  Think of how wonderful our treatment plans and ledgers would be!    

If you need help, let me know. 

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mdunham
Premolar III

Re: Calculating secondary insurance

Janelle,  thank you for your response.  I recently finished a discussion with the OPM (OfficPersonnelonell Management for Government)  GEHAs Product Manager and their Legal department as GEHA is  NOT calculating benefits as Secondary correctly.    Thier Dental Ref Guide calculation method is a bit different than you described.   I strongly suggest for both of you to review GEHA 's COB to be sure you are properly reimbursed.   

At least they are paying you somewhat better than some.   It seems their COB methods are unethically inconsistent.  My discussions with them have been lengthy, and today your COB payment now equals a third possibility of their incorrect COB calculations.    

 

Here is a link to their DRG-     https://cdn.benefeds.com/Education_Support/dental_brochures/GEHA2018.pdf 

 Barbara Truby, could incorrect COB be the reason why your totals are "incorrect"?  In other words, you could have incorrect reimbursements from GEHA as Secondary and therefore it only appears that your system is wrong?

GEHA should subtract the primary payment from their allowable and then remit payment which does not exceed their allowable.  This can be found beginning on page 12 of the link above.    If you need contact emails and phone numbers to voice your concerns on inaccurate COB calculations and to obtain correct payment I can provide them.

Good luck Ladies!  Be diligent, we have a tough job!   

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