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dental3208
Canine III

Insurance information for allowance table editing

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Hi all! I am working on creating our allowance tables and therefore our bluebook from scratch. We hadn't been utilizing this feature in our office and it will be a great help when it is up and running. I am a little confused on what documents I need from insurance companies and then steps after that. I have received hard copies of almost all of our in-network ppo insurance companies fee schedules and created allowance tables using those. However, I just watched a recorded online training webinar about the bluebook and allowance tables and it mentioned 1. deleting codes that aren't on the hard copy but in our Fee0 schedule - so I am not sure what that means because I thought that if it wasn't on their fee schedule they wouldn't cover it and 2. how are the alternative benefits found out so I can apply them in the correct allowance tables? Also, should I be getting schedules from each insurance company that I have in Softdent (even our out of network)? Thanks in advance - this is a crazy confusing process! 

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Moderator
Moderator

Re: Insurance information for allowance table editing

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Hey Greta
for your first question " deleting codes that aren't on the hard copy but in our Fee0 schedule - so I am not sure what that means because I thought that if it wasn't on their fee schedule they wouldn't cover it "

i assume that in that video they created the allowance table by choosing  " use fee0 amounts " or option 2 " copy from existing table " 

that will copy all codes from fee0 and add it to the newly created allowance table , then you have to go to view codes then edit each individual code's fee to match the "hard copy" fee , that will leave some codes that you have in fee0 but not in the hard copy in allowance table with your original fee0 amount this will mess the estimation for these codes , there for they advised to delete these codes from the allowance table 

if you were to choose option#3 ( make an empty table ) then adding codes from the "hard copy " and only the codes that are in the hard copy so you got nothing to worry about 

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Moderator
Moderator

Re: Insurance information for allowance table editing

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for the 3rd question " should I be getting schedules from each insurance company that I have in Softdent (even our out of network)?"

using allowance tables will make it easier for you to update the allowed amount for all insurance plans in a copmany at once in the future , so i would say yes that will be useful for you to get allowance tables from all insurance co you're dealing with 
though you cant use allowance table on all insurance plans ( that will depend on the insurance plan type ) 

i found this explanation of ins plans types and difference in their calculations 

There are multiple estimation types that affect the way in which the coverage and bluebook amounts are used.

Flat Fee:

The insurance plan pays a flat fee, or pre-defined amount for certain types of procedures. There is no maximum allowed amount, nor can Allowance Tables be attached.

Method - Flat Fee

Total Fee: $63.00 = T
Ins. Pays: $50.00 = I
Pat Pays: $13.00 = P

P = T - I

Percentage:

The insurance plan pays a percentage of an allowed amount. The patient pays any amount in excess of the allowed amount.

Method - Class%

Total Fee: $63.00 = T
Allowed Amount: $50.00 = A
Percent Covered: 50% = C
Ins. Pays: $25.00 = I
Pat Pays: $38.00 = P

(A x C) = I

P = T - I

DMO/Capitation:

The insurance plan pays a flat amount or "plan fee" and the patient pays the remaining amount. There is no writeoff involved.

Offices generally receive a monthly insurance plan check regardless of the amount of patients seen under a certain company. These checks are entered in the "Transactions" option of the insurance plan. Allowance tables can not be added to this type of insurance plan. Generally DMO/Capitation plans go by overall coverage amounts as opposed to individual bluebook entries.

Method - Cap.

Total Fee: $63.00 = T
Plan Fee: $50.00 = F
Ins. Pays: $40.00 = I
Pat Pays: $10.00 = P

P = F - I

Percentage PPO%:

The insurance plan will pay a percentage of an allowed amount, the patient will pay the remainder of the allowed amount, and the rest will be written off.

Insurance companies send offices a maximum amount they will pay for certain procedures. The office should be entering these amounts in to an Allowance Table and then setting the correct coverage amounts in the individual insurance plans. This will keep the office from having to re-enter the allowed amounts multiple times on each separate insurance plan. Write-offs can be automatically posted, but are generally posted manually once the check is received. As long as the allowance table and insurance coverage percentages are correct, using Automatic Write-off is flawless.

Method - Class%

Total Fee: $63.00 = T
Allowed Amount: $50.00 = A
Percent Covered: %80 = C
Ins. Pays: $40.00 = I
Pat Pays: $10.00 = P
Write-off: $13.00 = W

(A x C) = I

P = A - I

W = T - A

Flat Fee PPO:

Flat fee PPO plans pay a flat rate for specified procedures.

To estimate insurance payments for flat fee PPO plans, set up accurate payment values in the bluebook or allowance table for all procedures. If there is no bluebook entry for the flat fee PPO insurance plan, the percentages specified on the Coverage tab of the Insurance plan window are used. Specify whether a deductible applies to each procedural class when entering dental PPO plans.

Method - Flat Fee

Total Fee: $63.00 = T
Allowed Amount: $50.00 = A
Ins. Pays: $40.00 = I
Pat Pays: $10.00 = P
Write-off: $13.00 = W

P = A - I

W = T - A

Flat Medicare:

If the insurance plan pays a flat fee for procedural costs based upon the Medicare plan's allowed amounts, select Flat Medicare.

Method - Flat Fee

Total Fee: $63.00 = T
Allowed Amount: $50.00 = A
Ins. Pays: $40.00 = I
Pat Pays: $10.00 = P
Write-off: $13.00 = W

P = A - I

W = T - A

Percentage (%) Medicare:

If the insurance plan pays a percentage of the procedural costs based upon the Medicare plan's allowed amounts, select % Medicare.

Method - Class%

Total Fee: $63.00 = T
Allowed Amount: $50.00 = A
Percent Covered: %80 = C
Ins. Pays: $40.00 = I
Pat Pays: $10.00 = P
Write-off: $13.00 = W

(A x C) = I

P = A - I

W = T - A

Medicaid:

This estimation type is used in conjunction with most Medicaid plans and changing to this estimation type will affect certain provider or patient IDs that are printed on insurance forms. It calculates via a set amount for the plan fee with a patient co-pay. There is no write-off associated with Medicaid plans. Generally offices receive a bulk check from the insurance company that can be added in to the plan's transactions. Medicaid plans are rarely (if ever) set as "Benefits to Patient". Medicaid plans can not attach to Allowance Tables.

Method - Cap

Total Fee: $63.00 = T
Plan Fee: $50.00 = F
Pat Pays: $10.00 = P

P = T - F

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dental3208
Canine III

Re: Insurance information for allowance table editing

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This is great info - thank you! 

Yes, I used the Fee0 schedule since each company was different in their prices, but ours obviously stayed the same. The first question I meant to say is should I be deleting the codes that I've copied from our Fee0 schedule to the insurance company allowance table that are not on the fee schedule I received. I think that is what they meant about messing up the estimations, so should I delete them from the allowance table and re add them as a bluebook entry to get accurate estimations?

I am confused about what my next step(s) are in regard to making these tables as accurate as possible before even linking them to the correct company. It is my understanding that I would need to have several different, for example United Concordia, allowance tables with their corresponding group numbers to link to the employer to create the bluebook. 

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Moderator
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Re: Insurance information for allowance table editing

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the short answer for the first part , yes delete the codes from your allowance table if they are not included in the hardcopy , no need to add them to bluebook either 

united Concordia for example will have 10 insurance plans each has a different group number \ employer though they all share same allowed amounts \ allowance table ,  though their bluebooks are different cause each ins plan coverage information is different 

so step 1 make the allowance table exactly as the hard copy 
make ins plan exactly as it is supposed to be  ( estimation type , coverage tab information , deductible info , maximum coverage ..... ) 
attache the allowance table to insurance plan ( if applicable  depends on the plan type )  , that will auto-create the bluebook for that insurance plan 
if any upgraded codes or manual tweaking needs to be done in allowance table you can edit it at this point

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mdunham
Premolar III

Re: Insurance information for allowance table editing

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Greta, remove codes from the fee schedule that are not on the fee schedule.   If your contract states for instance that Pano's will NEVER be covered for any of their policies within that insurance company.  You could add the PAno code into fee schedule and then select the "upgrade procedure" box, in which the patient would now owe your fee for that service.     This would prevent you from having to add that code as zero coverage in the blue books for every plan.  

I have sent you a message regarding some tidbits that will help you with downgrades etc.   If you need help, please feel free to call me at 757-427-7130 and I can walk you right through it.  

Also, your state legislature rules on Non-Covered Benefits is very important when setting up Bluebooks and Fee Schedules.  What state are you in?

jesslingle
Canine III

Re: Insurance information for allowance table editing

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I am going to tell you what I have learned about dental insurance networking and try to speak to what you have to understand from the very beginning. Please disregard if you already know these things but they were helpful to me!

1) Your doctors are contracted or "preferred providers" with dental networks not insurance companies.  The terminology is very important to understand when trying to get info out of insurance companies on the phone.

2) Find out what dental networks your docs are contracted with. (I did this a back door way by calling insurance companies and asking what network they paid us through).

3) Insurance companies 'rent' dental networks.  Some insurance companies own their own network and some do not.  Some insurance companies rent multiple dental networks and will pay you based on the network that you have contracted with that pays the least (saves them money). For example, Blue Cross Blue Shield uses many dental networks- Dental Network of America/Maverest/Connection Dental, etc.  If you are contracted with any of the dental networks, you are a preferred provider for BCBS. BCBS does not have it's own dental network so DO NOT title an allowance table BCBS or you will never get all this figured out.

4)Google the dental network's provider service number. Call them and request a current fee schedule (aka allowance table) and a client list.  Start by adding the allowance table and title it by the network name.  For example if you are contracted with Dental Network of America (DNOA), title that allowance table as DNOA.  Then if you have Blue Cross Blue Shields plans that are paid via DNOA--you will use the DNOA allowance table when creating a BCBS insurance plan.

5)Bluebooks are a different animal than allowance table but are super important.  The fastest way to start fixing errors is to set up your posting preferences to update the blue book when posting.  This way, anytime you get a payment that is not paid as expected, SD prompts you to correct that specific code to be estimated correctly the next time.

6) Other notes--- sometimes the same dental networks go by different names. For example, Connection dental is also known as PPO USA.  They try to keep things simple that way!

I could type forever on this subject.  I have a 2 hour presentation I do to teach how to navigate insurance contracts. And its always changing! Let me know if you have any questions.  

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mdunham
Premolar III

Re: Insurance information for allowance table editing

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All of the described contracting and third-party payor information should be within your contracts and amendments.  Third-Party Payors often switch Administrators throughout the year, and it is frustrating at best.    However, you can eliminate participation in Dental Companies third-party payors within your contract, or by writing your contracted insurance company and ask to withdraw your participation in the third-party networks.      Should providers wish to remain providers with these third-party payors, you can request a list of third-party payors in which lease their network.  Updating this list bi-annually is generally a good idea.      Most often the list can be found on your contracted plans' website.

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dental3208
Canine III

Re: Insurance information for allowance table editing

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Thank you so much for this information! I am printing it out now to

highlight and see exactly what I need to do. Jess - that sounds like an

incredibly informative presentation, is it a webinar? I would love more

information and all the help we can get!

jesslingle
Canine III

Re: Insurance information for allowance table editing

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It is really something I do for employee training purposes.  I took over in a situation where the provider contracts that had been entered into years before and no one really knew where they were or even exactly who was contracted with who.  I had to do a lot of investigation and request a lot of documentation.  I learned by trial and error.  I am working to get everything together in a power point.  When I do I don't mind emailing it to you but it may be January! I actually may teach a few CE courses here in OK. So much of the work depends on how many contracts your dentist(s) has/have.