If it's not covered...

[Jorgebon]

In Puerto Rico, and in many states, when an insurance company does not cover a procedure you can charge your regular office fees or whatever fee you agree with the patient. Open Dental does not yet provide a solution for this scenario. The closest thing is defining a plan as PPO Percentage and if that insurance company does not have a fee listed for that procedure then your regular fee will be used. The problem is when they do have a fee listed which they use for only some plans. In that case OD will give the patient a discount based on the difference between the regular fee and the insco fee. You have to check every treatment plan and manually click on the "Do not bill to ins" checkbox on all the procedures that aren't covered. If we overlook a procedure and the discount stays, we loose money. We try to make sure this does not happen but inevitably every now and then a procedure gets overlooked and we don't get paid our just fee. In other times this would not make a big difference, but if you know anything about how bad the economy is in Puerto Rico you will understand how frustrated we feel when this happens.

I started a feature request a long time ago addressing this problem. It is feature request #166. As you can see from the number, it was one of the first requests made about seven years ago. If this seems like a good feature for you, please vote on it. Your help will be much appreciated.

[ryansmithdds]

I would really like a solution to this....... Maybe 5 or 6 years ago this was not a big issue but now i think over 30 states have passed this law. I am still charging patients the discounted rate or contracted fee even with insurance is maxed because i cannot figure out a way or system to easily do this in open dental. I am loosing a ton of money every week by this not being a feature.

This is a really big deal. If a lot of dentists are not asking about this it is because they are ignorant and blinding loosing lots of money......

Please open dental! This is absolutely a critical issue and would allow everyone who is in network with insurance to collect more money!!

Thank you!!!

oh and i also have lost some hope on the feature request system.... there are so many things requested all the good stuff and important things just get watered down

[boboffice]

Insurance being maxed does not mean procedures are "non-covered" benefits. In most states, and for sure here in CA, you must still offer the PPO negotiated fee when a patient is maxed or frequency limitations apply. Here is the CA law with the pertinent phrase highlighted.

Assembly Bill No. 2275
CHAPTER 673

An act to add Section 1374.195 to the Health and Safety Code, and to add Section 10120.3 to the Insurance Code, relating to health care coverage.

[ Approved by Governor September 30, 2010. Filed with Secretary of State September 30, 2010. ]

LEGISLATIVE COUNSEL'S DIGEST

AB 2275, Hayashi. Dental coverage: noncovered benefits.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of its provisions a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires contracts between plans or insurers and providers to be fair and reasonable and requires plans and insurers to reimburse a claim for covered services within a specified period of time of receiving the claim.
This bill would, with respect to a contract between a health care service plan, specialized health care service plan, or insurer covering dental services and a dentist to provide dental services to enrollees or insureds, prohibit the contract from requiring a dentist to accept an amount set by the plan or insurer as payment for dental care services provided to an enrollee or insured that are not covered services under the enrollee’s contract or the insured’s policy. The bill would also prohibit a provider from charging more than his or her usual and customary rate for dental services not covered under a health care service plan contract or health insurance policy. The bill would require the evidence of coverage and disclosure form for a plan contract or health insurance policy covering dental services that is issued, amended, or renewed on or after July 1, 2011, to contain a specified statement regarding noncovered services.
Because a willful violation of these requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
DIGEST KEY
Vote: majority Appropriation: no Fiscal Committee: yes Local Program: yes
BILL TEXT
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

SECTION 1. Section 1374.195 is added to the Health and Safety Code, to read:
1374.195. (a) With respect to a contract between a health care service plan or specialized health care service plan and a dentist to provide covered dental services to enrollees of the plan, the contract shall not require a dentist to accept an amount set by the plan as payment for dental care services provided to an enrollee that are not covered services under the enrollee’s plan contract. This subdivision shall only apply to provider contracts issued, amended, or renewed on or after January 1, 2011.
(b) A provider shall not charge more for dental services that are not covered services under a plan contract than his or her usual and customary rate for those services. The department shall not be required to enforce this subdivision.
(c) The evidence of coverage and disclosure form, or combined evidence of coverage and disclosure form, for every health care service plan contract covering dental services, or specialized health care service plan contract covering dental services, that is issued, amended, or renewed on or after July 1, 2011, shall include the following statement:
IMPORTANT: If you opt to receive dental services that are not covered services under this plan, a participating dental provider may charge you his or her usual and customary rate for those services. Prior to providing a patient with dental services that are not a covered benefit, the dentist should provide to the patient a treatment plan that includes each anticipated service to be provided and the estimated cost of each service. If you would like more information about dental coverage options, you may call member services at [insert appropriate telephone number] or your insurance broker. To fully understand your coverage, you may wish to carefully review this evidence of coverage document.
(d) For purposes of this section, “covered services” or “covered dental services” means dental care services for which the plan is obligated to pay pursuant to an enrollee’s plan contract, or for which the plan would be obligated to pay pursuant to an enrollee’s plan contract but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, or alternative benefit payments.
SEC. 2. Section 10120.3 is added to the Insurance Code, to read:
10120.3. (a) With respect to a contract between an insurer covering dental services and a dentist to provide covered dental services to insureds, the contract shall not require a dentist to accept an amount set by the insurer as payment for dental care services provided to an insured that are not covered services under the insured’s policy. This subdivision shall only apply to provider contracts issued, amended, or renewed on or after January 1, 2011.
(b) A provider shall not charge more for dental services that are not covered services under a health insurance policy than his or her usual and customary rate for those services. The department shall not be required to enforce this subdivision.
(c) The evidence of coverage and disclosure form, or combined evidence of coverage and disclosure form, for every health insurance policy covering dental services, or specialized health insurance policy covering dental services, that is issued, amended, or renewed on or after July 1, 2011, shall include the following statement:
IMPORTANT: If you opt to receive dental services that are not covered services under this policy, a participating dental provider may charge you his or her usual and customary rate for those services. Prior to providing a patient with dental services that are not a covered benefit, the dentist should provide to the patient a treatment plan that includes each anticipated service to be provided and the estimated cost of each service. If you would like more information about dental coverage options, you may call member services at [insert appropriate telephone number] or your insurance broker. To fully understand your coverage, you may wish to carefully review this evidence of coverage document.
(d) For purposes of this section, “covered services” or “covered dental services” means dental care services for which the insurer is obligated to pay, pursuant to an insured’s policy, or for which the insurer would be obligated to pay pursuant to an insured’s policy but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, or alternative benefit payments.
SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.

[Jorgebon]

When I say "not covered" I don't mean maxed out or refer to some limitation. I'm talking about procedures that a plan does not cover. For example, a plan that only covers a limited set of codes, but the patient needs other procedures. I can mention some plans that only cover exams, extractions and a prophy. If the patient has caries, the patient would need to pay for those restorations out of his own pocket. Even so, more and more US jurisdictions are passing laws that allow the dentist to bill the patient whatever fee has been determined between the dentist and the patient for any non covered benefit, even those that would have been normally paid by insurance before it was maxed out or limited by some circumstance.

See this report stating that there are now 36 states that have passed non-covered services laws: http://www.ada.org/en/~/media/ADA/Advoc ... mer_2015_I

[boboffice]

When I say "not covered" I don't mean maxed out or refer to some limitation. I'm talking about procedures that a plan does not cover. For example, a plan that only covers a limited set of codes, but the patient needs other procedures. I can mention some plans that only cover exams, extractions and a prophy. If the patient has caries, the patient would need to pay for those restorations out of his own pocket. Even so, more and more US jurisdictions are passing laws that allow the dentist to bill the patient whatever fee has been determined between the dentist and the patient for any non covered benefit, even those that would have been normally paid by insurance before it was maxed out or limited by some circumstance.

See this report stating that there are now 36 states that have passed non-covered services laws: http://www.ada.org/en/~/media/ADA/Advoc ... mer_2015_I

I was referring mostly to Dr. Smith's answer above, where he refers to insurance maximums and noncovered services.

[Tante]

Anyone figured out how to do this?
My staff is is great with people not computers. I too would like our office fees to show whenever there is no coverage.

[rhaber123]

I am not sure if this will help
This also happens to us when an insurance changes the ADA code to a lower one.

I have a small office, and this is what we do:

1- My receptionist, with a pencil, she always write on the EOB the amount of adjustment that was allowed by the insurance:
(Provider fees - Insurance Fees = Adjusted amount)

2- When posting the payment, she compares this ADJUSTED amount to the WRTITE OFF that OD is trying to make.
if they match, great
if they do not match, she will figure it out or shows it to me

***May be OD can track that if a doctor accept electronic EOB , and electronic payment,
OD software could compare the ADJUSTED amount on the EOB and the WRTITE OFF amount generated by OD

***With some insurance, on the EOB it should say that this specific procedure was not covered.