We are all familiar with the equation below. If you are out of network with any of your patient's insurance its important to provide accurate estimates and avoid surprise bills. We cant pre-auth everything in time for treatment. As we all know insurance companies do not disclose their contract "allowable fees" to out of network dentists. The only place we see these fees are AFTER treatment is completed on an EOB or before on a Pre-auth.
% Coverage X "Allowable Insurance Fee" = Payment Made
I have Easy Dental software and am considering changing to Open Dental. I may not be understanding how Open Dental creates estimates, so please correct me if I'm wrong. I want to be wrong. Below is my dilemma.
In order to utilize the information on EOB's to create accurate estimates, Open Dental requires the employee to enter 3 items by ADA code; the "allowable insurance fee", % coverage and the payment. The % and "allowable insurance fees" are then used through Blue Book to calculate future patient estimates. The actual payment made is not used to create future estimates. If the employee does not enter the allowable insurance fee and % items off an EOB consistently the blue book feature will not compile a database with which to create estimates. If the "allowable" fee and percentages are not entered Blue Book defaults to the entered % X UCR to estimate insurance payments. % X UCR almost never results in an accurate estimate of insurance coverage.
For the past 10 years I have compiled a huge Payment Made table across so many insurances I cant even count. It tells me what an insurance company (by group number) paid on each code. In Easy Dental, you only need to enter the payment amount from EOB's and this is used to create future estimates for all patients with that group number. You do NOT enter the "Allowable Insurance Fee" or the coverage %. You enter the payment and simply check the box "add to payment table". The only time you don't "add to payment table" is if a deductible was removed or if the patient was short on benefits. When you create an estimate, Easy Dental uses the most recent Payment Made amount for a particular code within the same insurance group number.
For example, Patient A & B both have the same insurance plan and are out of network at my office. Pt. A gets a crown D2740 in January and three months later Pt B gets a crown D2740. My employee added Pt A's insurance payment into the payment table so we know exactly what Pt. B will owe on their crown. It's essentially using the same equation above but instead of counting on staff to accurately enter three items by code for each EOB payment, they only need to enter one. Not to mention the entered payment amount is automatically checked for accuracy against deposits, whereas the entered allowable insurance fee and % are not.
Is there a way in Open Dental to utilize the payment tables we have compiled for creating estimates? Does Open Dental have this functionality? I'm short staffed like most and don't think asking my staff to enter three items for every code off EOB's is a great idea. Counting on them to pre-auth every procedure also seems unrealistic. I cant afford to create inaccurate estimates for a year while we build the data in blue book. UCR X % estimates are not an option.
Please let me know if you see a solution to this in Open Dental that incorporates the valuable payment tables we have built. Our estimates are usually dead on or under $10 off. If we don't update insurance coverage %'s every year, it has no effect on our estimates because the most recent payment is pulled to create estimates. Doing something we already have to do, enter payments, automatically updates our estimates.
Sorry for the long post, I hope someone had this same situation and found a way to use the payment made data in Open Dental for estimates.
Thank You!
Dilemma OON Estimates, Help!
Re: Dilemma OON Estimates, Help!
Using Open Dental "Blue Book" is what you need.
Contact Open Dental conversion team and ask them if they can convert your already collected data in the "Blue Book"
Or we do the following in our office for the last few years. We created our estimated fee schedules.
When we get an out of Network patients, my receptionist will call the insurance and try to see how much the insurance will pay for the prophy, Exam , and a one surface filling. And she pick one of the low fee schedules we created in OD
More info here
http://opendentalsoft.com/forum/vie ... 5&p=30913
Contact Open Dental conversion team and ask them if they can convert your already collected data in the "Blue Book"
Or we do the following in our office for the last few years. We created our estimated fee schedules.
When we get an out of Network patients, my receptionist will call the insurance and try to see how much the insurance will pay for the prophy, Exam , and a one surface filling. And she pick one of the low fee schedules we created in OD
More info here
http://opendentalsoft.com/forum/vie ... 5&p=30913