I had an office reach out to me just last week to tell me they had dropped several of their low insurance contracts. They processed all of the necessary paperwork with the insurance company and they sent personalized letters generated using Easy Dental to the patients affected by the change. But the one thing they did not plan for was the change in insurance estimations.
Here is how it works when you are out-of-network with an insurance company:
An insurance company will recognize a maximum allowable fee, which will directly impact the amount the insurance company will reimburse on a covered service. The maximum allowable charge can be determined by one of a few different methods, depending on the insurance company. The methods for determining the maximum allowable fee include: Fee Schedule, UCR and MAC (maximum allowable charge). Beware the language the insurance companies will use for the maximum allowable fee.
Here are a few examples:
Fee Schedule: You may be most familiar with the type of fee schedule which is provided to you upon contracting as an in-network provider. This is a set pricing for each ADA procedure code. The pricing is determined by the insurance company and depending on your office pricing for procedures, the fee schedule of the insurance company may be higher (or in many instances it is lower!) than your office fees.
UCR (by fee schedule): At times, the insurance company may use the term UCR (or Usual, Customary and Reasonable) to describe a fee schedule. This really is just a fancy term the insurance company has developed to describe set amounts the company has put in place for each procedure.
Maximum Allowable Charge: This term is used by a few key insurance companies to define the allowable fee they will recognize for a procedure. AKA – Fee Schedule.
UCR (by area): I find the UCR by area concept to be the most intriguing, complex and variable of all maximum allowable fee types. Insurance companies define an office “area” by its ZIP code. The idea behind this type of allowable fee determination is that the insurance company will take an area average for all dentists’ charges to determine the reasonable pricing for a procedure.
How to give more accurate estimates using Easy Dental
Providing your patient with an accurate estimation of insurance coverage is pivotal to keeping the patient happy. After all, happy patients are more likely to return for additional treatment. Let’s take a quick example of your patient, Suzy, who needs a crown (D2740). Your office fee for the crown is $1,200 and Suzy’s insurance plan will reimburse at 50% of a maximum allowable fee of $1,000.
An Easy Dental estimate will provide the patient with $600 as the estimated out-of-pocket expense.
However, the Easy Dental estimate is inaccurate. Suzy’s insurance plan will reimburse 50% of $1,000 – which is $500. You must “tell” Easy Dental that Suzy’s plan will pay $500 for her crown by updating the Override Insurance Estimate.
- Double-click to open the Edit Procedure dialog box.
- Check the Prim. Ins. box to enter 500.00.
- Preview the Easy Dental Estimator for Suzy’s new (accurate) insurance estimate.
- The Override Insurance Estimate will only apply to that service. It does not apply to any other service for that patient, or for any other patients.
- The insurance Payment Table can be utilized to create a memory of payments received from an insurance company. Payment Tables will apply to all patients covered by that insurance group/plan.
- The Insurance Override Estimate applies to downgraded services, such as posterior composites.
David Broom is Senior Director of Product and Business Development. David has a master’s degree in Information Technology (IT) from the University of Texas in Dallas and has more than 35 years of experience from many global companies such as Hitachi Vantara, Methode Electronics, and Keane, Inc. In his current role, he is responsible for all aspects of the product management and field service teams at Henry Schein TechCentral, which identifies the ideal advanced technologies to meet the unique needs of the dental market and ensure that dental offices are using the right IT to be more efficient and effective.