Help with estimated insurance

[afeuer]

I have been using trial version to compare OD to our current PMS MOGO. I am trying to figure out the best way to set up estimated insurance payments. I have read all the online manual pages about setting up fee schedules and insurance plans.

Currently the system we use automatically guesses what it thinks the insurance company will pay. After a few years of data it seems to be right about 50% of the time. Our office staff has never been too pleased with this system, even though it does save time when it works.

- How can I make OD automatically estimate payments as soon as a procedure is set as complete or even when the insurance claim is submitted?
- How does OD figure out what the estimates are going to be? Is it common for practices to maintain the fee schedules from every single insurance plan they accept?
- (general PM question) If you are not sure what the insurance company will pay, do you ask your patient to pay a portion now and then adjust it when you hear from the insurance company, or do you wait to bill them until after the insurance pays?

Thanks,
Adam

[jordansparks]

You're talking about the specific situation where you are not enrolled with the plan in question. And you don't know what their allowed amounts will be. So your estimates end up being a bit high. This is usually only noticeable if your fees are significantly higher than the carrier UCR fees. And there are some carriers that are notorious for having lower UCR fees. So, one simple option to handle those kinds of plans is to create an allowed fee schedule. Lower all the fees on the fee schedule to what you think one of these types of carriers will cover. Maybe figure a 20% reduction from your standard fees. You don't have to fill in all fees, just ones you care a lot about. Then, simply assign this allowed fee schedule to plans, and the estimates will be based off of the allowed fees. So you really only need one allowed fee schedule to make this system work. But if you get more accurate info about certain plans, you could set up a few more allowed fee schedules to handle those specific plans.


One of our planned features is a Coverage Book. This is similar to the the blue book or coverage table feature in some other dental software, and sounds like what you might be using with Mogo. It would uses previous payments by an insurance plan to make estimates on other patients using the same plan.

I couldn't tell from your question if you were also mixing in the different situation where you are an enrolled PPO provider. If that is the case, then enter the fee schedule and use the PPO type.

[asanders]

Along these same lines . . . How close are we to having real time claims? If I understand it correctly, we would know exactly what the patient's portion is before they walk out the door. I'm salivating at the prospect.

[jordansparks]

That may or may not ever happen. It depends on the insurance companies. For example, in the pharmacy industry, they've had real-time claims for quite a few years, but they had to give up certain freedoms to do it. They had to become an "in network" pharmacy in order to get those real-time results. And, of course, that cuts into profits.

[sparkly]

the coverage book will be great. i know that when i used mogo, the difference in fees ended up being under $10 per procedure (maybe even less) since estimating patient portions keeps up with the 'amount allowable' by insurance... just by inputting the last insurance check. can't get much easier than that without becoming labor-intensive (and impractical) for staff.

that reminds me, i have to go vote... ...

[afeuer]

I think there is something I don't understand. If the insurance estimate is off by $10 or $100 you still have to go in manually and edit the amount after the fact. Also, if you billed the patient for the estimated amount and you were wrong, you are still going to have to bill them a second time to balance their account. Either way, this is extremely inconvenient.

Right now we treat PPOs that we participate in and ones that we don't the same way. We don't bill the patient until after we get payment or a rejection from the insurance company and then we adjust the balance. Then we bill the patient. Mogo is pretty good at learning, and like I said it's probably right a little over 50% of the time... But we're not going to bill patients wrong that often. So as it stands we don't bill patients until a month or more after the fact, which sucks.

So, my question is how do other people handle this situation in the office as well as in OD? Do you have your office manager spend all day once a month going through updated fee schedules?

[jordansparks]

Billing them a second time for some small change is not extremely inconvenient. At least they paid most of what they owed the first time around. And frequently, if they are having some more treatment done, the small change will just get rolled into the payment for their next treatment. We recommend getting your estimates as close as possible, having the patient pay based on the estimate, and then dealing with discrepancies later. If you implement this, you will immediately receive tens of thousands of dollars in cash because of the shift in the timing of your AR.

[sparkly]

Right now we treat PPOs that we participate in and ones that we don't the same way. We don't bill the patient until after we get payment or a rejection from the insurance company and then we adjust the balance. Then we bill the patient. Mogo is pretty good at learning, and like I said it's probably right a little over 50% of the time... But we're not going to bill patients wrong that often. So as it stands we don't bill patients until a month or more after the fact, which sucks.

whoa. i jsut reread your post. are you saying that you are in-network for some PPO's and you're billing your UCR and waiting for what the insurance company puts down on the EOB as write-off???? or do you have your PPO fee schedule in OD and connected to the in-network patients? this would make a big difference in your estimates; your contracted PPO fee is what it is so calculate the patient copay from that. you should be very close on estimates vs just guessing (and waiting).
i don't agree that billing a patient a second time is not extremely inconvenient (eg i do think it's a pain in the butt) but it comes with the territory. if you're really worried about getting paid or what patients may think, estimate high and credit back $5-10 vs chasing someone down for that amount. that scenario feels different for the patient and you (and your checkbook) than the scenario you're currently in.
all that said, the coverage book has a DIRECT impact on the bottom line of the practice as you and jordan have both said in different ways. hopefully others see the benefit and impact of the feature.
the only workaround that i use (which gets really old really fast): the day before, the assistant goes thru the schedule and manually changes estimates for major procdures based on past history with the ins company. it's a pain but that's where we've traditionally gotten caught with big gaps in estimates.