Best practices for PPOs with OD

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JLM
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Best practices for PPOs with OD

Post by JLM » Thu Jul 18, 2013 8:33 am

Working with our trial conversion....

What is the best practice for dealing with PPOs under OD? Best practice generally meaning what ever is the least amount of work for the receptionists...

For a decade with dentrix, we have used different fee schedules for the PPOs. Is that a bad idea under OD? Should we be converting to using writeoff's instead?
What's the point of having a bazillion entries that total into a figure that's only good for inducing profound depression?

Jim Margarit

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Arna
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Re: Best practices for PPOs with OD

Post by Arna » Thu Jul 18, 2013 1:20 pm

Good afternoon Jim,

The best practice would be to use PPO plan types with Insurance Fee schedules attached. This will allow Open Dental to treatment plan using your UCR fees and Open Dental automatically calculates writeoffs. The writeoff amounts will show on patient treatment plans as a 'Discount'. In the account module, the writeoffs are lumped into the anticipated insurance payment, so patient portions still reflect the money owed after treatment. Additionally, you may want to consider whether you want to be able to track your writeoffs for accounting purposes or not. Using this PPO method allows you to track writeoffs per insurance carrier to analyze your relationship with them.

If you do choose to set up Open Dental to just chart the insurance amount (fee schedule strategy in Dentrix), special care will need to be taken if an insurance check comes in with a greater amount than the fee schedule anticipated. Because Open Dental will be substituting the UCR fees to insurance fees, accounting will need to be modified in this instance. This is not a recommended strategy, however it is possible.
Please see http://www.opendental.com/manual/insplantypes.html for more information.

I am curious as to what you mean when you say "profound depression"? Are you referring to sticker shock for the patient or a drop in production for you?
Entropy isn't what it used to be...

Arna Meyer

JLM
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Re: Best practices for PPOs with OD

Post by JLM » Thu Jul 18, 2013 4:41 pm

I'm not sure I really want to see how much money I am writing off each year to PPOs. It's not real money and prompts unnecessary regret. The reality is that shunning PPOs in my town would leave me with 5 patients a day, a one op practice *AND* I would have to do my own prophys.

It is like regretting being married to my wife because I am giving up a shot at dating women like Linsay Vonn. Or counting up the money I have lost by not playing my favorite lottery numbers.

In other towns and other practices it could be a useful analytic. For me, write-offs just clutter up the ledger with the illusion of lost income.

The one advantage I see to writeoffs is that insurance companies are jamming me into a catch-22. We bill our UCR to Delta PPO and we bill the actual patient cost to the secondary non-PPO insurance. Companies are starting to refuse to pay secondary claims unless the two amounts match. Basically, they are demanding that I either send fraudulent information to Delta or fradulent information to them. Doing writeoffs avoids that hassle 5 or so times a year.

Jim Margarit

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Arna
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Re: Best practices for PPOs with OD

Post by Arna » Fri Jul 19, 2013 10:04 am

Who doesn't want to do their own prophys?!?

Coming from a foreign land of 'no such thing as PPOs', I totally understand your predicament. Working with insurance companies is like the awkward first stages of dating (but unfortunately Linsay Vonn is still not involved).

Considering you have used Dentrix the way you have for so long, your office would be well equipped to continue doing what you do now. In Open Dental speak, that would be using Category Percentage plans with Normal Fee Schedules. You will want to make sure that the 'Claims show UCR Fees' is checked in the insurance window. This will put your Office Fees on to that claim form. Just know that you may confuse some of our support staff here. We normally do encourage the PPO route, however we do have a few ex-Dentrix users that prefer to do it this way, and my suspicion is you will join that group.

If I understand you correctly, your catch 22 will be avoided by using that nifty 'Claims show UCR fee, not billed fee'.
Entropy isn't what it used to be...

Arna Meyer

JLM
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Re: Best practices for PPOs with OD

Post by JLM » Sat Jul 20, 2013 4:22 pm

I think that we will stick with what we are used to.

Assuming that I submit my UCR to both insurances, how do we let the secondary ins know that the patient received a discount of $xxx.xx and the secondary benefit should not exceed $yyy.yy or the patient will receive more than 100% benefit for the procedures? Do we have to write that on the claim manually (like we do now)?

Jim

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Arna
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Re: Best practices for PPOs with OD

Post by Arna » Mon Jul 22, 2013 4:01 pm

A lot of offices submit a copy of their Primary EOB. Is this not the case for you?
Entropy isn't what it used to be...

Arna Meyer

JLM
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Re: Best practices for PPOs with OD

Post by JLM » Mon Jul 22, 2013 6:12 pm

Arna wrote:A lot of offices submit a copy of their Primary EOB. Is this not the case for you?
Assuming deductible has been met, UCR is $800 and patient is actually charged $700 per maximum allowed by primary PPO insurance...
Typical EOB from PPO primary: Amount charged: $800 Amound approved: $700 Benefit: $350

We used to submit $700 to the non PPO secondary. They would pay $350. Patient gets 100% benefit.

Now they are demanding that we submit $800 as the fee. Then they pay $400. Patient gets $750 for a $700 fee.

How do I prevent overpayment when we are forced to submit fees higher than the actual charged fees?

Jim Margarit.

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Re: Best practices for PPOs with OD

Post by bpcomp » Tue Jul 23, 2013 12:15 pm

Our office is almost entirely FFS and we are not in network with any (except a few state plans) insurance so if my thoughts are incorrect, that would be why.

If $800 is your regular fees and Primary only allows a contracted rate of $700 and they pay $350 on that that does not mean that $700 is the rate for the secondary insurance. If they are out of network or their contracted rate is $800 or greater, then they want to know your rate and not the contracted rate of the primary insurance. They do want to know what your primary paid and thus you send the primary EOB. The only part I'm not clear on is this.... if your patient has $800 of service and the total reimbursed is $750, do you keep the $50 more than the primary allows on the account as a credit benefit from the patient having dual insurance. Or do you accept it as payment for services rendered?

JLM
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Re: Best practices for PPOs with OD

Post by JLM » Wed Jul 24, 2013 1:13 pm

It's a quandary.
1) It is perfectly appropriate to send UCR to a contracted PPO because they will automatically adjust fees and will not overpay as long as my UCR is greater than the allowed amount.
2) It is fraud to bill the non-contracted carrier anything other than what I actually charged the patient. It is the same as waiving copays and billing full fee to the carrier. Yet this is exactly what they are insisting I do.

In response to your question, I thing the secondary insurance would say keeping the extra $50 or even giving it to the patient would be fraud.

So, I am trying to find a way to bill UCR to both and not commit fraud.

Jim Margarit

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Re: Best practices for PPOs with OD

Post by bpcomp » Wed Jul 24, 2013 2:57 pm

I am not a lawyer nor am I an insurance expert. All opinions expressed below are my own.

I believe that I understand your point but I don't think I agree with your interpretation. If you send your full fees to both insurance companies, then how is it fraud to receive greater than the contracted rate from the primary insurance from the secondary insurance who may either be paying up to the contracted rate they have with your office or the UCR that they assign you as an out of network provider?

Our office is contracted with a couple of state funded plans. If the patient has dual insurance then the non-state funded plan is always primary. The state funded plan typically pays 25-30% of our full fees. If the primary insurance pays more than the contracted rate of the state funded plan then the state funded plan doesn't pay but it can't determine that the amount we should receive from the non-contracted insurance is what their contracted rate is. We didn't charge our contracted rate with one insurance. We charge our full fees and then the insurance company determines if any benefits are owed based on our contracted rate with them. If in the rare circumstance the primary insurance pays less than the contracted rate of the state funded plan then the state funded plan will pay the difference up to their contracted rate. Not the UCR for the out of network primary insurance. Any difference between our rates and the maximum reimbursement we've received is written off. To use some made up numbers lets say we charge $100 for service and then submit to the primary insurance who pays us $50. We submit to the secondary who says the primary paid more than we would pay and so we won't pay anything for this visit. (secondary would have paid $30 if there was no primary.) We are not committing fraud for receiving the $20 difference and writing off the $50 balance on the account. We submitted to two insurance companies and received the maximum benefit allowed toward our full fee. If the secondary insurance pays more than the primary up to their allowed maximum, it's not fraud that they paid more than the allowed maximum of the primary insurance.

As I understand your interpretation then if you submit to two contracted plans then you must only accept a maximum reimbursement of the rate of the lowest reimbursing plan even if you have a higher contracted rate with the other plan.

JLM
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Re: Best practices for PPOs with OD

Post by JLM » Wed Jul 24, 2013 5:53 pm

Non duplication of benefits is a whole different, and evil, ballgame. ;)

I will put in a call to the Provider relations rep for my biggest PPO's and get their opinions and I will follow up here when I know more.

Jim

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