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jawdoc
Canine III

Treatment plan estimates

Hello! How are people verifying insurance benefits and calculating treatment plan estimates?  Are other offices still contacting insurance companies by phone?  We are enrolled with everification but have found that it only works with certain insurance companies and when it does work it is not providing all the information that we need to give accurate estimates.  We also check online benefits with the companies that offer that but find that we are still making a lot of phone calls to insurance companies.  We also manually calculate insurance benefits and estimated patient expense.  Is there a better way of doing treatment plan estimates?  We have not transitioned yet to the EMR Elite but hope to within the next year.  We are currently evaluating our office and looking for ways to eliminate paper for an easier transition.  We do not have all of our fee schedules entered into our system just our normal fee schedule.  If all the insurance company fee schedules are added in the system and updated yearly will the system automatically and accurately calculate the insurance due and patient due estimates including patient deductible and yearly maximum? We are looking for better ways of doing things.  Thanks!

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9 Replies
omsnashville
Premolar II

Re: Treatment plan estimates

We still call on Every. Single. One.

The majority of companies still don't provide enough specifics online (I don't know of any local medical plan that specifies about WT coverage online), so there is usually at least one piece of the puzzle we still have to call on- even to dental. Be it frequency limitations, missing tooth clause, waiting periods, or division of OMS services between basic and major levels... it is rare that we get enough info online to confidently quote an estimate.

We also still calculate all of our estimates by hand. WinOMS does not have the capability- even in EMR- to accurately calculate the patient due portion for you. The most it can do is give you the contracted allowable for each service; it cannot account for deductible, calendar year maximum, non-covered services, anesthesia minimum requirements, and certainly not for secondary coverage.

Although it would give us allowables, we still solely use our Standard Fee Schedule across the board. That way, we are billing our full actual charges to the insurance company, and our write offs are properly listed on the EOBs. If we were to use the insurance company-based fees schedules, we would have to shift the balance from "patient due" to "insurance due"- line by line for each item- before sending our e-claim.

Supplemental: We keep an Excel "Rolodex" of benefits for our most common employers in this area, so all 9 of our insurance coordinators can access it anytime to confirm some of our most common benefit quotes (ie- whether medical covers WT, or if dental covers implants, or other plan-specific specifications).

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jawdoc
Canine III

Re: Treatment plan estimates

Thank you!  That is very helpful information!

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carestreamjoey
Canine III

Re: Treatment plan estimates

Hey Jennifer.  Some offices use the eVerifications feature that comes with eClaims service.  It allows you to check benefits in the patient screen with the click of a button.  Some insurance companies are still not allowing that info to be accessed online so you may have to call to get all the info needed. 

To speak to the insurance due calculation....this topic is a hot one right now.  While WinOMS will allow you to get an estimate using fee and allowable schedules, it still doesn't factor in the deductibles or maximums.  (as Kristina stated above) 

This is at the top of the list of enhancements and I wouldn't be surprised to see it in the next version of the software.  (We are hoping to be able to show something at the User Summit towards the end of the year) 

Hope this helps. 

omsnashville
Premolar II

Re: Treatment plan estimates

Wonderful to know!

I just spotted this conversation on a SoftDent page, and it prompted me to think that we, too, would need a way to mark a procedure as excluded by that patient's plan, so that it is not subjected to the automatic pricing. Perhaps just a little check box in the item itself; better still if it could be something that is batch edited (like the referral source, etc.)

Thank you again!

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arcadiogomez
Canine II

Re: Treatment plan estimates

Jennifer, this is Arcadio Gomez, Oral Surgery eServices Specialist.  With regards to our eVerifications service, when you select the eligibility button, the system sends out an XML query (code) to the insurance company's database.  The code in the query covers all questions related to insurance eligibility.  What ever information the insurance company's system is prepared to respond to will be delivered back to you in real time.  The response will provide both Dental and Medical insurance eligibility information. Unfortunately, not all insurance companies have updated their systems, therefore some will provide plenty of information, some medium and some a yes or no.  When you come across these insurance companies that return little or just a yes or no with no specifics, please contact our eServices support group.  Our eServices group will put in a tracer to the insurance company letting them know that we have users that are not receiving adequate information. To contact our eServices support group please call: 800.262.8593

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jawdoc
Canine III

Re: Treatment plan estimates

Hi Arcadio, we are enrolled with eVerifications so we are familiar with the functionality of it.  When it works well it's amazing, fast and so easy but it only works with a couple of insurance companies not even a handful.  EVerifications would be a great feature if it worked with all insurance companies and provided all the information needed to give accurate estimates.  Maybe someday.... 

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arcadiogomez
Canine II

Re: Treatment plan estimates

Yes Jennifer, I agree with you, someday.  We are waiting for the insurance companies to all be on the same page and have their databases communications updated to provide full responses in real time. That's why we recommend to our customers to let us know which insurance companies are not providing enough info so that we can let them know.

Arcadio

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hnnobel
Canine III

Re: Treatment plan estimates

What my experience has been over the years is that a good portion, but certainly not all, Oral Surgery Practices use their fee schedules and usually call the insurance companies for estimates. Where I’ve seen this work well is with offices that use an Estimates Sheet and take down all information they get over the phone; who they spoke with, breakdown of benefits and so on. Then they scan the Estimate Sheet to the patient’s workspace to access when needed. At that point the original Estimate Sheet gets shredded.

In addition I’ve also have encountered Practices that ask for a certain percent upfront, for example, 30%, eliminating some of the need to call insurance companies. The though process is they receive payment for more than the patients portion that is due. It’s easier to give the patient a check for an overpayment then to have to try and collect the funds later on.

staceyw
Canine III

Re: Treatment plan estimates

We use the e verification and it works well for 50% of the insurances.  We also have created individual log ins for all the other insurances and try and go on line rather then using our phones.   This works well for us.  Metlife is the best!  we can submit a claim in real time same with Delta of NJ we can submit both claims and pre D.  United heath care dental has a great website to where you can look up by procedure code and it tells you the patients co insurance. 

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