"Blue Book" Ins Ests?

[drtech]

Entering itemized insurance payments: Entry speed has been improved because the Enter key now causes the cursor to jump to the next cell to the right. There is also a new column called Allowed. The numbers entered in that column will flow automatically into the allowed fee schedule.

Is this like a "Blue Book" feature as was discussed a while back to help with future ins estimates or is this something else?

[jordansparks]

It is indeed the blue book. Fee schedule management has been significantly improved and automated as well. So we now have full blue book functionality.

[drtech]

great! I think that is an excellent improvement to OD! Can't wait to try it out....

[sparkly]

oh this sounds great! i'll have to see where this is too next time i input a claim payment. If there's no 'allowed fee schedule' set up for the plan, will inputting a payment generate it automatically?

[jordansparks]

Allowed fee schedules are generated automatically at the time of plan creation. They are also generated automatically for all existing plans when you turn on this feature.

[sparkly]

i'm sorry, i haven't used this feature before so i'm not familiar with it. i read the manual information on how this is set up.
is it correct that i'd have to set up a fee schedule for EACH unique insurance plan so i can store the allowed fees?

for example, i have 1 standard fee schedule for the office that will be copied as the 'base'. When Joe with Aetna from Walgreens comes in, i need a schedule called AetnaWalgreens to store the allowed fee data. When Sally with BCBS from Walgreens comes in, i link a BRAND NEW schedule called BCBSWalgreens to store data. When Betty with MetLife from Acme Storage comes in, MetLifeAcme fee schedule has to be made and added.
is this correct? that means there will be as many fee schedules as there are guarantors since each family has its own insurance plan thru its own employer.

[jordansparks]

Deciding how to deal with your question is exactly why this feature took so long to implement. We decided to make the following assumptions:
1. This is a category percentage plan.
2. Out of network.
3. It is sufficient to create one allowed fee schedule for each unique carrier name.
So, there will be one Aetna fee schedule, one BCBS (and probably a few other variations like BlueCross), and one MetLife. Regardless of which employers are involved, the chances are very high that MetLife uses one "allowed" or "UCR" fee schedule for your region. So in the end, we decided not to track every individual plan, but to just track carriers. Feel free to object if this does not match your experience.

[sparkly]

ok, those assumptions help me understand this much better and see how it's meant to function.
unfortuntely, like you said, this is not the experience in my area. there's medium-size companies that provide *crappy* Guardian plans that are at 30th percentile and other companies that have purchased Guardian at the 90th. the main purpose/benefit of the coverage book would be to prevent from getting burned on collecting on those 30th percentile people but not penalize the 90th.
at least with the improvement, we have the ability to tag these rogue plans that need the coverage book the most when estimating copays. most ideally though, each plan would *automatically* keep a constantly-updated running track of current allowable fees based on claim information.
thanks again for the explanation!

[Jorgebon]

In my office we've used the allowed fee schedules feature extensively, so we've had something like a Bluebook for a long time. We see a few of those plans where they pay less than the regular carrier fee, so our solution has been to treat those plans as distinct carriers. For example, there is a carrier here that has their regular commercial groups, some Medicare Advantage groups and a state financed group for medically indigent patients. We consider each of those as separate carriers and have them defined as separate carriers in the "List Carriers" window, even though they have the same address and electronic ID.
Jorge Bonilla, DMD

[jordansparks]

So if you really want to track the two different kinds of Guardian insurance separately, there are two options:
1. Name the carriers differently.
2. Manually change the allowed fee schedules.
We still let you manually change the allowed fee schedules. In fact, there is now extensive support for managing your allowed fee schedules to be sure that they are all assigned just the way you want them. Our automation for assigning allowed fee schedules only happens as you create each new ins plan. The automation will be skipped if you assign an allowed fee schedule yourself. And there is no automation for existing ins plans. So you can safely change allowed fee schedules and be confident that the program will never automatically change them back without telling you.

[sparkly]

Our automation for assigning allowed fee schedules only happens as you create each new ins plan. The automation will be skipped if you assign an allowed fee schedule yourself.

thanks jorge and jordan for the info/suggestions. i'll go in and make new fee schedules to enable fee tracking for those rogue plans that are already in my system.

with respect to automation in your statement above jordan: if i have an existing plan to which i attach a newly-made allowed fee schedule, will i see the new columns of 'paid' and 'ALLOWED' when inputting claim payments?

If inputting a patient's insurance information, one still needs to [take the mouse cursor and] attach an Allowed Fee Schedule in the drop-down in order to implement this function--this is never automatic when an insurance plan is set up, right?

[jordansparks]

Everything I've said so far assumes you are on version 6.1, but that version has not even been released yet. I wouldn't try it until version 6.1 gets released. Maybe this week. And yes, it will automatically create and attach an allowed fee schedule for you.

[sparkly]

Everything I've said so far assumes you are on version 6.1, but that version has not even been released yet. I wouldn't try it until version 6.1 gets released. Maybe this week. And yes, it will automatically create and attach an allowed fee schedule for you.

ha. ok. still on 6.0.2, so that's why i was getting confused about the automatic part of it. look forward to this upgrade in 6.1 and will manually input allowed fee schedules for any existing plans that won't be grandfathered in by the upgrade.

thanks again for the explanation of the functionality.

[cneelley]

I am a little confused by the ongoing discussion. Somewhere in here Jordan says we can object to how many or how allowed fee schedules are created, by carrier or by employer or whatever else. I vote for allowed fee schedules by plan, not necessarily employer, and not by carrier. The reason being that the very same carrier will have different allowed fees for different employers, depending on which plan the employer purchases from the carrier. Each employer can and often does have a different plan from other employers. Some employess will have different benefit levels than other employees, the more they pay, the better the benefits. The ppo fees will be assigned by area, so will be the same, but sometimes the carrier will allow posterior composite benefits, and at other times will only allow amalgam benefit. So, it seems to me that allowed fees by plan makes more sense??? If it is the same employer and 2 or more different plans, then we say the employer and say which plan, in the title of the plan. Automated is fantastic.

Dr. Neelley

[jordansparks]

But there's not an easy way to automate that until the United States requires plan identification numbers. ID numbers for plans are in the works, so maybe this will get easier in the future.

[sparkly]

Dr Neelley, i agree with you that each plan should have its own allowed fee schedule/tracking capability. i was trying to figure out how to get past the shortcomings of the way this system has been set up so i can use parts of it NOW before it finally does become an actual fully-functional Bluebook.
Mogo was able to do this since its early versions. From my memory of mogo reports, i believe that each insurance carrier-employer-group # combo got assigned a number (like patients get ID's assigned as they get input) and this ID was used to track each plan's allowed fees. Just because there's no requirement of plan ID #'s doesn't mean the program can't generate them internally. i'm assuming that's one of the hard programming parts as been said many times before.

[jordansparks]

According to Dr. Neelley, carrier-employer combinations are not sufficient, and a plan description should be the unique identifier. The problem I have with this is that the front desk will not always know what the "plan description" should be.

According to sparkly, it should be a carrier-employer combination. I have seen that combo used to help with unique id within clearinghouse software before. But I don't think that would be any better than just using carrier.

I think the carrier-only strategy is a good first phase. I think it will solve the bulk of the problem. I want to try to minimize the number of automatically created allowed fee schedules. I think a second phase that might be considered later would be to differentiate by group number, group name, or plan description. We would probably let users specify this behavior for only certain carriers if they wanted.