Sunday, October 9, 2011

Fee Schedules or Write Offs . . . That is the Question

This is the hot topic in my home state of Washington since our largest dental insurance company recently slashed our filed fees by 15% or more on June 15th, 2011.  Several offices I work with have called me asking for advice on how to deal with it now that even the non-PPO plans are working under a much lower fee schedule.  Before I give my two cents I want you to understand the differences between using a fee schedule and using adjustments. 
Let’s talk write offs
Offices using the write off system bill out the full fee for the procedure and then perform an adjustment (write-off) on the ledger to account for the difference between the office fee and what the contracted fee is with the insurance company.  On their billing statements, patients see the full fee and also an adjustment showing how much money their dentist is losing by being a member of their PPO dental plan.  Also, in the write off system, the dental insurance companies are automatically billed the office’s higher fee, rather  than the PPO fee, which will help when the insurance company looks at how much of an increase to make to the fee schedule (even though we all  know this hardly ever happens).  
I love this method!  However, the Dentrix Treatment Planner doesn’t work optimally with the write off method, and this can create some challenges for your team.  So, it is important to know what your options are, so you can make the best choice for your office.
Here’s the challenge:  If you are using your office full fee and doing write-offs, the Dentrix Treatment Planner has no way of knowing how to account for that difference.  Your office team will be required to make hand written adjustments to the treatment plan estimate which can make it look unprofessional and messy.  Also, it will be challenging to collect on the day of service since the ledger cannot accurately calculate the patient’s portion if the full fee is being posted to the ledger.  Of course, even with this tricky calculator work, some offices still prefer to use this method.  But you should know that there  is another option – fee schedules -  that can work really well for you in the long run.
Fee Schedules – a little bit of management but lots of benefits
The fee schedules system is the preferred method for offices that are contracted with multiple PPO plans.  With this system, the office team must keep the fee schedules current, update the coverage table accurately and attach the fee schedule to the insurance plan properly.  
The most frequent comment I get from team members when I discuss this method with them is “I want to bill my full fee to the insurance company and that is why I have never switched over to using fee schedules.”  Great!  You can bill full fees and still use fee schedules.  I’ll give you more details on this in my next post, but for a preview - all you have to do is change the claim format to the DX2012F when you are attaching the fee schedule to the insurance plan (the F tells the Dentrix software to bill the fee schedule fee to the patient ledger and the full fee to the insurance company).
So what are the advantages of using fee schedules?  Collecting at time of service is accurate on the ledger; the treatment plan estimates are accurate, so you don’t have to do any manual calculating; and the production for the day will show a net production number instead of an inflated production number.   All of these are huge advantages for your team and your bottom line!
So, now you have the scoop:  Both systems work, and there is no right or wrong way to deal with PPO plans – but there are pros and cons to each, so you should choose thoughtfully.  Hopefully this post has helped you understand your options.  Next week I will walk you through the proper setup of the fee schedule method.

144 comments:

  1. So you billed the ins under ur office ffs and the insurance pay more and you already collected the patient's co pay base on the ins ffs. Do you have to refund the patient since they pay more

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    1. if the patient has two insurances and they cover 100% of the fee charged is it necessary to write off the agreed amount leaving the patient with a credit on the account.

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    2. False. The PPO adjustments (write offs) and payments from both primary and secondary, can NOT exceed the billed amount. Not the PPO allowed amount- the billed amount. A patient should NEVER have a credit on their dental account from insurance, or insurance adjustments, for them to use later.

      This however can be avoided. One way is to submit the primary EOB attached to the claim that you're submitting to secondary. Which should be done always-regardless.

      Also, if a patient is double covered, and both insurance companies are PPO with your office, you are to only use the primary insurance companies PPO adjustment. Not both. Using both can create false credits on the patient's account.

      Contrary to popular belief, it also is not the higher of the two PPO adjustments that you post. It is always simply primary's.

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    4. Correct, when the patient has dual insurance and the office is contracted with both then the primary is used for calculating the patients out of pocket.

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    5. What is the primary doesn't cover the procedure, then do you make a secondary insurance write off if the secondary covered the procedure?

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    6. What is the procedure was not covered by the primary insurance company and the secondary did cover it. Then would you make a write off using the secondary contracted fee's?

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    7. It still depends. Always wait until the secondary pays to take the write off because you only have to take one write off. For example; if the procedure was $100 and primary paid $0 but reduced the fee to $80, secondary paid $60 and reduced the fee to $70 then my calculations would be a write of $30 and patient owes $10.

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    8. If the patient is dual covered, what fee schedule do you use? the Primary or secondary?

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    9. Dentrix will use the Primary fee schedule to post to the ledger and the treatment plan. This is why it is very important to always use your full fee schedule on the insurance claim form because the secondary might have a higher fee schedule and you want to be able to tap into that for payment.
      Hope this helps,
      Dayna

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  2. We have dentrix g4 and we do not have claim format dx2007f. how can I add that to our dentrix?

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    1. Go to the Office Manager > Maintenance > Practice Setup > Definitions > click on the drop down menu and look for Claim Format, if you change the top one it will become the default.
      Hope this helps,
      Dayna

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  3. Does this same rule apply with non-ppo's? After both insurance companies pay sometimes the patient ends up with a credit.

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    1. Yes, but with a non-PPO situation your patients ledger is already showing the office full fee schedule so I am not sure how the patient would end up with a credit unless the patient over-paid and then you would owe the patient a refund.

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  5. To be certain I am understanding this correctly: A patient has two insurances - our office is PPO with the primary, but not with the secondary. We use the write-off system. This patient has ended up with an enormous credit (over $1000) due to the previous Receptionist incorrectly applying payments/write-offs for the two insurances. No patient payments have ever been, so this credit is definitely coming from insurance postings to the account. Legally, we do not have to give a patient a credit for having two insurances unless the patient is actually making payments in addition which account for the credit, correct? Thanks so much!!

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    1. That is correct. The patient is not due any money unless they have actually made personal payments and have over paid. Also, you might not owe any money back to the insurance company if they have not over paid on any of the procedure codes. Make sure you go through the account thoroughly to be sure. You are allowed to keep up to the full fee but not over that.
      Hope this helps,
      Dayna

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  6. I have a question:

    If our patient's are contracted with an insurance company, are we REQUIRED to write off the remainder of our office fee or can we charge the patient whatever is left over from the contracted fee?

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    1. If your office is contracted with the insurance company you cannot charge the patient the difference between the contracted fee and your full office fee. The patient only pays out of pocket up to the lowest contracted fee. If you are not contracted with the insurance company then you can charge the patient the difference between the plan amount and the office full fee.
      Hope this helps,
      Dayna

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  7. If you have the PPO fees set in the insurance plan info with the claim format as DX2007F will the office fee then show up on the claim form being sent even though the fee shows as the PPO fee in the treatment plan? My Dr. likes to see the write off and I am currently using a lot of white out. Thanks

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    1. Yes you are correct. If you are using the claim format DX2007 or DX2012F then the insurance claim ignores the ledger and pulls the fees from the main office fee schedule. Test it by printing a claim from the Office Manager batch before it gets sent out and you will see higher fees on the claim form than what shows on the ledger.

      For the treatment plans you can add a column for the patient to see the higher office fee if that would satisfy your doctor.

      Hope this helps. Have an amazing day,
      Dayna

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  8. What if the patient does not have double coverage, but the office personnel did not submit office fee schedule on claim, instead the lower PPO fee schedule was billed to the insurance. Patient paid her portion and ins paid then she ended up with a large balance. It was allocated back to provider but the EOB she received shows we collected more than we should have at time of service and she wants a refund. Do we owe her that money?

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    1. You can only collect up to the contracted fee. If she paid more than the contracted amount than you owe her a refund.
      Dayna

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  9. Do you make the contracted fee adjustment for both primary and secondary, if patient has dual coverage and we are contracted with both insurance company's. For example patient comes in for a crown we submit to primary with our office fee's and when we receive payment, we post the payment and make the contracted fee adjustment and then, we submit to secondary (again with our office fee's). They pay and then we post the payment along with our contracted fee adjustment with them. Which gives them a double write-off in a way...

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  11. I am new to insurance billing,and am tring to figure out which is best. If a patient has 80% coverage on restoration,and their portion is 20%. Does the patient pay us 20%,at the time of their filling,plus their deductible(if they haven't met it?) Or do we wait until we get paid for that claim? Also,what do we write off if the insurance doesn't pay their full percentage?
    Thank you

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    1. My recommendation is to collect the patient portion at the time of treatment, so you would collect the 20% plus the deductible if the patient has not met it yet. I do not recommend waiting until insurance pays if you are using fee schedules because the patient's ledger is accurate.

      If you are under contract with the insurance plan and they don't pay their full percentage then you need to find out why. If they are denying something on the claim then depending on the reason you can charge the patient the difference. The insurance company must honor the contracted fees and benefit coverage % from the employer.

      Hope this helps.
      Dayna

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  12. I recently took over a dental practice, and the person who was to train me left without notice, so here I am. clueless as to insurance claim processing, and what to write off. Basically, from what I can see from your post, and the questions asked by others, any difference in the amount that we charge our office fees, and what the insurance company 'says' we can charge, has to be written off, correct? Sadly, no one told me this, and although its only been 2 months, I'm angry. Also, what is your advice on this....since I did not know this rule, and was not shown it, do you think there is any sense in going back and reviewing that claims that I've inputted into the system, since I've already done billing, or should I just move forward from here and consider it a lesson learned? Also our associate dentist is getting paid on production....you can bet that I'll be updating our fees scheduled asap! Thanks, and thanks for your blog...I'll be watching for more questions/info in the coming weeks. Nancy

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    1. Hello Nancy,

      I am willing to help you if you email me privately so we can setup a time to talk on the phone. You can email me at dayna@raedentalmanagement.com

      Dayna

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  13. Hello Nancy. Thank you for this article. We use the DX2007F format which is very helpful. We are a PPO only practice but when a patient has two insurances we post our office fees then make adjustments after we receive payment from both insurances. I just wanted to clarify. Which PPO fee should we use to make the adjusments? Is it the primary or whichever PPO fee is lower? I haven' t been able to get a solid answer from anyone.

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  14. If a patient has dual insurance they are responsible for payment up to the lowest PPO fee. You would need to make the adjustment only after the secondary pays and you are allowed to collect up to your full fee.

    The rule is that the patient is only responsible for the lowest of the two PPO fees, however the office can collect up to your full office fee. So make sure you are always billing your full fee to the insurance companies when you use fee schedules.

    Hope this helps,
    Dayna

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    1. So if we bill our fee of 208.00 to Aetna the primary and their fee is 76.00, but they pay 10.40 due to a 50.00 deductible, then bill Cigna the secondary and their fee is 133.00 and they pay only 26.40, with a 50.00 deductible, the patient will owe us 39.20.

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    2. You are making me work here, gotta get out my calculator :) Yes, you are correct. The patient is only responsible for their co-pay up to the $76.00. Your office would have been allowed to collect from the insurance companies up to the $208.
      Hope this helps,
      Dayna

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  15. After reading all your responses (which I appreciate you taking time to blog) I want to insure I am understanding correctly, I have been paid by two insurance companies, they both paid at 80%. Usually the secondary subtracts what primary has already paid, in this case they didn't. So I should refund the patient what they paid out of pocket and we are allowed to keep the remaining (from ins) as long as it is not greater than our UCR fees? Am I adding up total claim payments ( 2 insurance companies) or is each payment calculated separate? EX: Delta pays $100, Cigna pays $100, totaling a $200 claim payment, our UCR fees are $180. Or is it $180 UCR Cigna paid $100, that's fine and Delta paid $100 our fee is $180, there would be a $20 refund on the account due to claim payments. We are contracted with both insurance companies.

    Thank you for your help in advance!

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    1. The rule is that the patient is only responsible for up to the lowest PPO fee, but the office is allowed to collect up to your UCR. In your example if both insurance companies combined paid you $200 but your UCR is $180 you would owe the secondary a $20 refund. In this example the patient should not have owed anything.
      Dayna

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  16. Thanks for clarifying a confusing issue. I think I understand things but I would like to throw out a couple of questions related to a real 'case'.
    -Patient looses job in corporate downsizing and is allowed to keep his benefits, a PPO plan from a major carrier for 6 months after termination, paying for them personally. Patient gets a new job during this period of time. Traditional FFS dental insurance from another major insurer is provided. Patient is now covered by two dental policies and wants to have a bridge from 29-30 constructed (D6752,D6242, D6752) along with two crowns (D2752) for #s 21 and 20.
    Questions: Who is the primary insurer? Which fee schedule is applicable to this treatment? FFS or PPO?
    Thanks.

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    1. When a patient is covered by a PPO plan the patient is still only responsible for paying up to the lowest fee, however my recommendation is to always bill out your FFS fees to all insurance companies because the office is allowed to collect up to this FFS fee. The patients out of pocket cannot exceed the PPO fee in this case.

      As far as who is primary and secondary you may need to call the insurance companies and ask, or just bill out the new one and let them coordinate.
      Hope this helps.

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  17. I am doing an account analysis on this pts account and we submitted a claim back on 7/30/2012 for $127. The primary paid $100, secondary then came along and paid $123 leaving an over payment of $96. This has never been refunded back to the secondary for over payment. What is the time frame in which one should NOT refund the ins co or is it the law that we have to no matter how long?

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    1. There is no law that states you must refund the insurance company unless they request it. However, I would remove that credit from the patients account so they do not accidently use up that credit and then the insurance company asks for their $96 back and you have to then ask the patient for it. That would not be good.
      Dayna

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    2. When you say remove the credit, how would you suggest this be done?

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    3. You would need to do a +adjustment from the patient account and a -adjustment to an account you setup to keep track of pending insurance refunds. You can create a "fake" non-patient account to keep track of money owed to insurance companies so you can easily refund it if you need to. If it was my office I would use the +Transfer Balance and -Transfer Balance.
      Hope this helps,
      Dayna

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  18. If a primary insurance pays nothing on a claim (due to ineligibility, out of network provider, etc), and the secondary pays (contracted provider), are we required to make a write-off for the secondary ins? Does the rule of lowest PPO fee still apply if it's the secondary? Example: Filling billed at $200 (office fee), primary pays nothing, secondary pays $80 with a max allowable of $100 on that filling. Does the patient pay $20 with a $100 write-off, or do they pay $120?

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    1. Yes, the rule applies to the secondary. In your example the patient pays $20.

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  19. Hi!

    We have a patient that has 2 insurances. We are in network for BOTH.The Pri only covers preventative and the secondary covers everything (prev/basic and major) So even when he has a filling done we always submit to the Pri knowing they are going to reject it , but we do that so the Sec can see it was submitted to the Pri and that they owe the full fee since this was not a covered procedure with the Pri. Now onto the Sec....so I submit the claim to the Sec with the EOB attached showing it was denied by the Pri and the Sec pays 80%. So the only adjustment I would take would be for the Sec...correct?
    $200.00 filling (our fee)
    $0.00 paid by Pri /not a covered service/ patient owes $200.00
    $200.00 submitted to Sec
    $100.00 fee scale fee for filling for Sec
    $80.00 paid by Sec
    $100.00 Sec adjustment
    $20.00 Patient owes this amount
    Thanks for your help Dayna!

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  20. Question: Our office is in-network with primary (UC) & out-of-network with secondary (Delta). Primary paid in full at 100% and we wrote off the difference. Can I submit a claim to the secondary even if the primary paid in full?

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    1. First, make sure you are always sending your full UCR fees to the insurance company. In your example, did the primary pay 100% of your full fee or the PPO fee? You should absolutely send a claim to the secondary. For one thing they may pay up to your full fee and they need the patient billing history.

      Remember, the patient is only responsible for out of pocket up to the lowest PPO fee but the office can collect up to the full UCR fee from the insurance companies.
      Dayna

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    2. I meant -100% of the PPO fee. Okay, so let me ask you this, most Delta plans will assign the benefits to the subscriber if the office is out of network. That would mean that we will have to follow up with Delta because we do not get EOB's and then bill the patient for whatever amount Delta paid to them?

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    3. If you are non-participating with Delta then you would be billing your full office fee to the patient and Delta. If the insurance checks are going to the patient then I would collect 100% from the patient, send the insurance claim as a courtesy and immediately make a $0 payment on the claim.

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  21. Here is my dilemma. Recently began working in a dental office that is processing both the primary and secondary dental claims at the same time. Am having a hard time attempting to change this method. Is it legal or okay to process both the primary dental insurance and secondary at the same time. Or should we process the primary dental insurance claim wait for the EOB and payment if any then process the secondary insurance claim. Now I have asked the this particular question with no definitive answer as well. How often does the secondary pay with out the EOB from the primary? However, I am worried that we are in correcting processing both on the day of treatment.

    Thank you

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  22. was trying to read everything and it got kinda confusing. i was told always do primary IWO. for example Fed D is always primary- we submitted & left pt with coinsurance $145 and allowance of $172, then submitted to UCC and pd $64. but UCC allowance is $91- which write off do we do? shouldn't the patient be responsible for there coinsurance?

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    1. Sorry, I don't know what IWO is. The patient is only responsible for out of pocket expense up to the lowest PPO fee allowable. So in your example the patient cannot pay more than $91. However, the office can collect from the insurance companies up to the full office fee. Your example is a little difficult to follow, but you might not have to do a write off at all.
      Dayna

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  23. I have read your response on 2/17/2014, and our office has been following your guidance. I have also received information from another office that we can charge the higher of the 2 PPO fees. When calculating pt. co-pays, If our office is out-of - network with Primary insurance and in-network with secondary insurance, which fees do we honor? Is there a calculation worksheet to determine the patient's co-pay after both primary and secondary has paid? We want to make sure we are charging pt. with the legal co-pays, yet insuring our office is receiving maximum allowance. Can you provide us with a legal reference when charging co-pays for dual insurance?

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    1. This comment has been removed by the author.

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    2. I understand that you stated the lowest PPO fee schedule should be followed. However, is it due to a contractual obligation, a legal one or is it just a courtesy to the patient. I was once told we should honor the primary ppo fee schedule only as a matter of office policy. Was the office within its rights to make that decision?

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    3. It is the office's contractual obligation to honor the lowest PPO fee. I have not heard that the primary fee schedule rules.

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  24. My doctor says there is a way in Dentrix to not have any write-offs....he even says to change the fee and not show the 10% write-off we give to senior citizens, I think this is incorrect..I use the PPO fee schedules for the insurances we participate with, but explained will still may have write-offs due to downgrading etc. He says he wants a true figure for production. I let him know we can run reports that show production and we can subtract out the adjustments, but he still insists there is something in Dentrix that will automatically do this and will show the true production..PLEASE help.

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    1. The only way to see true production on any of the reports is to use your reduced fee schedules. On the daysheet you can check the box "Compare to fee schedule" and this will give you a net difference between the office full fee and the reduced fees being posted. Maybe this is what he is talking about. Also, check out my PPO Analyzer report at http://www.greatminds.com/products/PPOAnalyzer.aspx

      Thank you,
      Dayna

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  25. Re: Your Sept. 8, 2014 entry about PPO writeoffs--what is your source for the rule you stated? Have been researching this and come up empty. Would like to have the source in case a patient ever questions why we are doing only the write off for the policy with the lowest fees rather than a wrtieoff for both policies. Thanks!

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    1. I have sat in on many insurance and PPO seminars by Dr. Charles Blair and also subscribe to his Insurance Solutions Newsletters. Whenever I have a question about insurance there are a few people I go to who are very connected to the insurance world; they are Dr. Charles Blair, Theresa Duncan, Dana Moss and Lois Banta. You can reach out to any of these people and they will be extremely helpful.
      Thank you,
      Dayna

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    2. Although it may be changing soon, with the direction our nation is moving, I believe each state determines how insurance companies behave.

      In the state of Utah, we have different requirements based on if we are contracted with one or both of the providers.

      If we are contracted with both insurances, we are allowed to charge the highest of the two fees.

      If we are contracted with just the secondary provider, we are allowed to charge our full regular fee which may leave the patient with a balance owed.

      If we are contracted with the primary insurance, but not the secondary, we can only charge our contracted fee. (I have been told that: "Any amounts received in excess of the fee, belong to the patient, since we have only received the money due to the assignment of benefits").

      UTAH STATE CODE R590-131-3. Definitions.
      c. If a person is covered by two or more plans that provide benefits or services on the basis of negotiated fees, any amount in excess of the highest of the negotiated fees is not an allowable expense.

      d. If a person is covered by one plan that calculates its benefits or services on the basis of usual and customary fees, relative value schedule reimbursement, or other similar reimbursement methodology and another plan that provides its benefits or services on the basis of negotiated fees, the primary plan's payment arrangement shall be the allowable expense for all plans. However, if the provider has contracted with the secondary plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the primary plan's payment arrangement and if the provider's contract permits, that negotiated fee or payment shall be the allowable expense "used" by the secondary plan to "determine" its benefits.

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    3. Thank you for the details. I am going to forward this to my contacts.
      Dayna

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    4. I was under the impression that our contract with each insurance carrier determines when and what we need to write off. Is this not the case? I know some things, like if a service is not covered by the insurance company whether or not I still have to honor our contracted rate is dependent on which state you are in, but I've never heard that I can forego the secondary write off altogether if we are not contracted with the primary carrier. Please update us on what you find out from your contacts. Thank you!!

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    5. I was under the impression that our contract with each insurance carrier determines when and what we need to write off. Is this not the case? I know some things, like if a service is not covered by the insurance company whether or not I still have to honor our contracted rate is dependent on which state you are in, but I've never heard that I can forego the secondary write off altogether if we are not contracted with the primary carrier. Please update us on what you find out from your contacts. Thank you!!

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  26. I have a situation where a patient has dual insurance coverage and we are in network with both insurance companies. When a patient comes in for any restorative work, our office has always collected both deductibles (if not already met) and our price of nitrous, as most insurance companies do not cover this. Parent has paid and we have received payment from both insurance companies and, without any contractual write off's, we already have a credit on the account. If I were to take the higher write off, to benefit the patient, it would create a credit of more than what the parent paid to begin with. In this instance, would I make my adjustment to show a credit of only what parent paid at the time of service and send them they're full amount back or would I not take any write off and only refund parent the credit on the account. I have spoken with secondary insurance and they are adamant they have not overpaid. Side note, both insurance companies have denied nitrous which is why I'm hesitant of sending the parent back the full amount. Any tips or suggestions?

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    1. If the patient account has a credit balance and there were no contractual write offs then I am assuming that the insurance companies paid on a higher fee schedule then you have posted to the patients ledger. It could be that the fee schedule that was posted to the patients ledger needs to be updated. Dentrix always uses the primary fee schedule to post to the ledger and then if you are sending full fees to the insurance they will be paying on the full fees. If you collected the deductible and the insurance did not take the deductible out of claim then you would owe the patient back the deductible payment.
      Dayna

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  27. Thank you for this blog. It has been quite interesting. I would like to have a question/answer verified, if you wouldn't mind. In the situation working with 2 contracted insurances; I understand the the patient's obligation is only the difference between what the insurances have paid and what the lowest contracted fee is, but if after receiving payments from both insurances, they have paid more than what either of their fee schedules have indicated...is it really true that we are allowed to keep the combined payments up to our UCR fees? And if so, is the allowed expense then, our UCR fees, and not either of the negotiated fees because the claims went out with our UCR fees?

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    1. Yes, you are allowed to keep up to your full office fee. This is why it is so important to bill your full fee to the insurance companies. You would do a + adjustment to the patients account to off set the credit, the credit does not belong to the patient it belongs to the office.

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  28. Example: A patient has dual coverage and our office contracts only with the secondary coverage. The primary coverage will only send the payment to the patient. Contractually, how much can we/should we collect from the patient on the day of service? We have come across some secondary plans that do not pay anything because they do not offer coordination of benefit. Any advice would be very helpful. :-)
    Thanks in advance

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    1. If the secondary has a non-duplication clause then they will not pay anything until the primary is maxed out. If the primary pays the patient only then I would pay that primary claim off with a $0 payment and send it off to secondary immediately. If you are contracted with the secondary you will need to honor your contractual obligations to that plan.

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  29. If I file $100 for someone with double insurance. Primary pays $80 with a $20 write off and secondary pays nothing with a $20 write off. Do I take both write offs because then the patient would end up with a credit? Or....what if primary pays $50 with a $20 write off and secondary does not pay anything with a $20 write off. Do we take both writes offs of just one? Would the patient owe $10 or $30?

    Thank you so much.
    Lisa

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  30. No, you do not take both write off's. Always wait until the secondary pays to take any write off. You only have to adjust down to the lowest PPO fee. The patient does not end up with a credit balance.
    Hope this helps,
    Dayna

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  31. Example: 2 procedures were done, one for $987.00 (our full office fee) and one for $45.00. The $45 charge is a non-covered benefit under both primary and secondary insurances, (we are contracted with both) therefore the patient would owe this full amount. The $987.00 was covered by the primary, at $446.50 and the secondary, at $231.50. The patient paid $246.00 up front at the time of treatment. To date both insurance companies have paid a total of $678.00 of the $987.00 billed for that specific procedure. The lowest contracted fee of the two insurances is $513.00. So normally, that w/o would be $474.00. I understand that I am not taking write offs for both companies, but do I just take a lower than normal write off and reimburse the patient her out of pocket since the payments of both companies are greater than the lowest contracted fee?

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    1. You are correct, you will need to refund the patient the $246 and your write off will be $309. Between both insurance companies you received $678 so you will take the write off down to this number not the $513.
      Hope this helps
      Dayna

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    2. So I am confused now. We did not collect more than the negotiated fee from the patient (246 of 513), and the dual insurances paid 687. Together all 3 paid less than the UCR of 987. So why do you refund the patient if the office is allowed to collect up to the UCR?

      Delete
    3. The patient should not have paid anything because she has dual coverage for this procedure. The insurance companies paid the contracted fee in full so the patient does not pay. If the patient would have been maxed out then she would have paid $513. You can keep what ever the insurance companies pay over the contracted fee.

      In this example the full fee is $987 and the contracted fee is $513 which would have made the adjustment $474 but because the insurance companies paid $678 the write off is only $309 so the office saves money.
      Hope this helps,
      Dayna

      Delete
  32. I apologize in advance if this question has already been answered. I read in the previous comments that only the primary write off is taken when the provider is contracted with both insurance companies. My example: Our fee billed to the primary is 69.00 and they pay 46.40. The secondary pays only $5.00. Both payments from the primary and secondary total 51.40. The primary write off is 16.00. That leaves a remainder of 1.60 of our office fee. The secondary lists a write off of $3.00. I just want to be sure that we are not required by law to use part of the secondary write off to apply towards the remaining balance. Do we write off up to our URC? Or is the patient responsible for 1.60? Thanks so much!

    ReplyDelete
    Replies
    1. You don't state what the contracted fees are. Is the $69.00 billed to the primary your full office fee or the contracted fee? Always take the adjustments after the secondary pays. The law depend on your contract with the insurance plans. I always stay on the safe side and say that the patient only pays up to the lowest contracted fee.

      Delete
  33. Can you please tell me how to enter multiple fee schedules into Dentrix G5?
    Thanks,
    Mishelle

    ReplyDelete
    Replies
    1. First, enter the names of the fee schedules in the definitions. Go to Office Manager > Maintenance > Practice Setup > Definitions, then in the drop down menu find Fee Schedule Names. Then to add the fee's into the fee schedules go to Office Manager > Maintenance > Practice Setup > Auto Fee Schedule changes.
      Hope this helps,
      Dayna

      Delete
  34. Hi, I am wondering about dual insurance when we are contracted with the primary and not with the secondary. In this case the primary pays on a very low fee schedule and the secondary would usually pay off UCR, however, I just received the EOB from the secondary and they only paid the difference between the contract fee and what was paid. Example:
    Our fee: 335
    Primary PPO fee: 170
    Primary paid 80%: 136
    Secondary paid: 34
    I was expecting secondary to pay 199 since they also cover at 80% and would have paid $268 had they been primary.
    Are they right in only paying the remaining 20% off the primary PPO fee??
    Thanks! :)

    ReplyDelete
    Replies
    1. They could be, it all depends on the language of the contract. It could be some clause or frequency on that procedure code or a non-duplication clause in the secondary contract.
      Dayna

      Delete
  35. Question: we are having issues getting our treatment plans to show the correct numbers that are posted in the fee schedules. Any idea how to fix this? Basically we end up with angry patients because the amounts showing are way higher than what they really should owe!

    ReplyDelete
    Replies
    1. First, check the fee schedules and make sure they match the list from the insurance companies. Next, make sure the Coverage Table is correct for the plan. Then, when you are using fee schedules do not use the Payment Table except for specific procedure codes (nightguards, posterior composite downgrades, perio maint, etc) if you have lots of codes in the Payment Table this will make your estimates wrong. Then if you still need to troubleshoot check to make sure on the procedure code you are not checking the box "Primary Ins Override" except when you need to.

      Hope this helps
      Dayna

      Delete
  36. Hi, In all of the past comments you are talking about PPO plans. Does this mean just being in network or actual PPO plans? We are in network with Delta Dental Premier and not the PPO. Would this make a difference in the write offs?

    ReplyDelete
    Replies
    1. Yes, being in network with the Dental Premier is still a discounted plan. Anytime you need to make an adjustment between your full fee and an insurance fee this is considered a in-network or PPO plan and I would use a fee schedule to manage it. When I worked in dental practice we were only in network with Delta Premier not PPO and I setup a fee schedule so my treatment plans and patient ledgers were accurate because the Delta Premier fee schedule was lower than our full fee schedule.

      Hope this helps
      Dayna

      Delete
  37. We have a patient with dual insurance both through herself. We are in network with only the secondary(Metlife) and not the primary(Blue Shield FEP). Our UCR for the service is $275, the primary pays $42 and the secondary pays $113 taking the total paid to $155. My understanding is that I have to write of the $120 difference between our UCR of $275 and Metlife's(in network) contracted fee of $155.

    Also if we are in network with both insurances someone has, do we take the primary adjustment, secondary or just the lowest in network rate of the two insurances?

    ReplyDelete
    Replies
    1. Yes, you are correct. You will write off down to the contracted fee with Metlife. The patient pays up to the lowest contracted fee.

      Hope this helps,
      Dayna

      Delete
  38. Hi Dayna,

    I have recently started at a new office with the previous front office manager already gone so I had no one available to train me! I am working at updating all of the fee schedules, and we are using G4. I did not find the initial claim format you suggested to make sure that insurance is not using the fee schedule amount billed but the highest fee schedule possible in case they make any changes..... We are currently using 'DX2007' as the claim default format, and when I tested this patient and printed the claim I noticed the fee printed on the claim, was the fee schedule amount. Is this a problem? Or do companies just disregard this amount depending on what claim format you are using?

    Just want to make sure before I get too far ahead of myself I don't create a mess!

    Thank you,

    Kelsey

    ReplyDelete
  39. Hello Kelsey,

    If you do not have the claim format DX2007F or DX2012F then you can add it into the Definitions. Go to the Office Manager > Maintenance > Practice Setup > Definitions, then click on the drop down menu and find Claim Format. You can edit the DX2007 by adding an F on the end of it or just add the DX2007F in the list.

    The claim form with the F at the end will ignore the ledger and add the office full fees to the claim form.

    Hope this helps,
    Dayna

    ReplyDelete
  40. Hi Dayna, had a question I submitted a Pre-Authorization to an insurance company the patients insurance does not a cover a procedure but, on the Pre-Authorization they have an allowed fee the patient has to pay out of pocket which is a lot less than the amount billed out. We are a participating provider with this insurance company if we go ahead with procedure for patient do we only bill the allowed amount by the insurance company to the patient and have to write off the difference even though the procedure is not even a covered benefit under the patients plan or can will bill patient the full amount. Thank you for your help. Maria

    ReplyDelete
    Replies
    1. Even though the procedure is not covered the insurance company will only allow a UCR fee. If you are contracted with the insurance company you must adhere to this fee and cannot charge the patient more than this fee. You can enter this allowed fee into the fee schedule for is insurance plan or you can bill out your full fee and do an insurance write off.
      Hope this helps

      Delete
    2. In Pennsylvania, if the procedure is not a covered benefit under a plan, dentists are allowed to charge up to their full fee even if they are contracted with that plan. I believe this vary per state.

      Delete
    3. If you are allowed to charge the full fee then I would flag that insurance plan so you can bill it appropriately in the treatment plan. Remember if you are using the "F" claim form you will always be sending out full fee and you can make an off setting adjustment on the patient ledger.

      I have noticed this is plan specific but never heard it is state wide. Is it if the patient lives in a particular state or if the insurance company is in your state?
      Dayna

      Delete
    4. This Ameritas website has links to 35 out of the 50 individual state's legislation. (https://wf.employeebenefitservice.com/wps/wcm/connect/Storefronts/obc/1398878240638) In these states, Insurance companies are not allowed to require providers to discount non-covered services regardless of the provider contract. I'm still searching for Utah's law because I really don't want to write off over $3,000 on an optional cosmetic case of 10 Veneers.

      Delete
    5. It is where the services are rendered. Here is the link regarding this but I am unsure about the other states.

      https://www.padental.org/Online/Advocacy/Laws_and_Regulations/The_Impact_of_SB_1144.aspx

      Delete
  41. Hi Dayna,
    Do we have to send a claim to the secondary if the primary has paid a hygiene visit at 100%. Our concern is that the patient has 2 exams per year on the secondary, and if we don't bill the secondary, then we would be able to get 4 exams per year. Thank you.

    ReplyDelete
    Replies
    1. Hello . . . that would be deceiving the secondary and potentially be considered insurance fraud if you were ever audited. Now the likelihood of that happening is very unlikely, however if you are billing a different code or withholding information intentionally to get more out of the insurance company and you were caught you could be fined or forced to re-pay the money you received.

      I know this was not the answer you wanted to hear but I am just looking out for your legal best interest.
      Dayna

      Delete
    2. I'm a bit confused. If the primary paid 100% of the office fee then a secondary claim doesn't need to be submitted, right? I understand if they paid 100% of the insurance allowance and there is a remaining amount, then yes, a claim should be submitted? Am I understanding this correctly?

      Delete
    3. If you are contracted with the insurance plan you may still be obligated to report a claim to the secondary even if there is nothing owing. They might require this information for frequencies.
      Dayna

      Delete
  42. I know you have probably answered this before I have read the above posts but still want to verify I understand correctly.

    Primary is PPO
    Secondary we are considered a Premier Provider but not in network
    Dont take write off on primary until after secondary pays
    Primary pays full contracted amount
    Secondary pays full allowed amount
    Secondary payment creates a credit on account
    We get to keep up to full billed amount
    The payment from secondary that created credit goes where?

    ReplyDelete
  43. Ok, my question. Total billed amount $1830. Not contracted with either ins. We have patient pay $366 up front. First ins pays the max $1000, I send the EOB to the secondary with a claim and they pay $1384. Now the total paid for service is $2750. I sent refund to PT for $366 and refund the secondary ins $554 because we can't collect over our billed fees. Is this right?

    ReplyDelete
  44. You cannot collect more than your full office fees. If the $1830 is what you would charge a cash patient then you are correct to refund the insurance company because they overpaid for the services.
    Dayna

    ReplyDelete
  45. Patient has dual insurance (Metlife/Delta) in network with both(PPO) primary is maxed secondary has full remaining. Question is can we bill with primary fees(pt maxed)or bill with secondary fees.

    Note: primary fees are a lot lower than secondary.

    Thank you

    Charla

    ReplyDelete
    Replies
    1. No matter what your PPO contract status is with primary or secondary you always want to bill out your full office fee to the insurance company. If you are using fee schedules in Dentrix and the primary has a lower PPO fee schedule then these are the fees that will be posted on the ledger, but if you are sending out full fee on the insurance claims then the secondary will pay off your full fee anyway. In this situation the patient may end up with a credit balance so you might need to do a +adjustment to offset the credit balance.

      Hope this helps,
      Dayna

      Delete
  46. Well, I have got the best information from here the site is fully stuffed with the knowledgeable information. dentist Arlington texas

    ReplyDelete
  47. Hello my question is as follows; Patient has two insurances Primary is pays for the prophy leaving the copy of 30.00. Send the remaining balance to secondary provider. Secondary does not pay for the copay stating primary paid more that their fees there fore are not paying the 30.00 copay. Now should I bill the patient for the copay or write it off?

    ReplyDelete
  48. It depends on what the allowable fee is. If your fee for the prophy is $100 and both insurance companies allowed the $100 fee then the $30 co-pay is the patient's responsibility.
    Hope this helps,
    Dayna

    ReplyDelete
  49. Hi Dayna,

    We're stuck with an insurance issue and after reading through some of the Q/A on this site i'm sure that you can help us out.

    One of our patients has dual coverage and we are in network with their secondary.
    Total procedures charged out at standard fee amount = $4,543.00
    Estimated patient amount that was paid up front = $690.93
    Primary Ins (not in network) paid = $2,000.00 (ins maxed)
    Secondary Ins (in network) paid = $1,500.00 (ins maxed)
    Allowable amount per secondary ins is $2,603.60
    Amount that secondary has listed as non chargeable: $1,939.40
    Amount that they have listed as subscriber amount due is: $1,103.60
    The total credit we came up with after we took the total from the non chargeable = $2,603.60. $2,603.60 - secondary pmt $1,500.00 = subscriber liability amount of $1,103.60, but since primary paid $2,000.00 wouldn't it be $2,000.00 - $1,103.60 = credit of $896.40
    Would we just refund the patient the $690.93 and adjust off the difference of the remaining credit ($896.40 - $690.93 = $205.47 adjustment).
    Any help would be greatly appreciated.

    ReplyDelete
  50. Hi Dayna,

    We're stuck with an insurance issue and after reading through some of the Q/A on this site i'm sure that you can help us out.

    One of our patients has dual coverage and we are in network with their secondary.
    Total procedures charged out at standard fee amount = $4,543.00
    Estimated patient amount that was paid up front = $690.93
    Primary Ins (not in network) paid = $2,000.00 (ins maxed)
    Secondary Ins (in network) paid = $1,500.00 (ins maxed)
    Allowable amount per secondary ins is $2,603.60
    Amount that secondary has listed as non chargeable: $1,939.40
    Amount that they have listed as subscriber amount due is: $1,103.60
    The total credit we came up with after we took the total from the non chargeable = $2,603.60. $2,603.60 - secondary pmt $1,500.00 = subscriber liability amount of $1,103.60, but since primary paid $2,000.00 wouldn't it be $2,000.00 - $1,103.60 = credit of $896.40
    Would we just refund the patient the $690.93 and adjust off the difference of the remaining credit ($896.40 - $690.93 = $205.47 adjustment).
    Any help would be greatly appreciated.

    ReplyDelete
  51. I think you are right on as long as the secondary EOB took into account the primary payment. This one is a little complicated. Thank you for sharing.
    Dayna

    ReplyDelete
    Replies
    1. The secondary EOB did not show the payment that was made by primary, but we know the primary EOB was received because it was attached electronically and secondary would not have processed the claim without having the primary EOB...so..would the same adjustment still apply?

      Delete
  52. Hello, I just wanted to know how to manually calculate the ins write off and when exactly is it applied? for instance if an ins. pays 100% but there is still a portion not paid which is the pt portion how do i get that amount current in the ledger or will it not show? what do i label the amount as? credit adj.?

    ReplyDelete
    Replies
    1. If you are contracted with the insurance company and have filed fees then if they pay 100% of that filed fee you are obligated to adjust it off. If your filed fee is already applied to the ledger and they pay 100% and there is still a patient balance then you need to figure out what went wrong. If you are not contracted then the patient pays the difference.

      Hope this helps
      Dayna

      Delete
  53. When a primary ins pays for a calim in full and its posted, when it asks to make a secondary claim do i press yes or no? i figure since its been pair there is no reason to send or is my assumption wrong? please help i have soo many quiestions.

    ReplyDelete
    Replies
    1. if primary pays in full and you are contracted with the secondary then I would send a claim. You can send it and then pay it off immediately so it doesn't sit on your Insurance Aging report. It is important to keep the patients history accurate with their dental plan.

      Hope this helps,
      Dayna

      Delete
  54. With using the fee schedule, is there a report in Dentrix that I can run to see what the write off was for a particular insurance?

    ReplyDelete
  55. With using fee schedules is there a report to run that will show the write off amounts for a particular insurance company?

    ReplyDelete
  56. Is there a report that can be run to show what the write offs are for the year with an insurance company that you are contracted with?

    ReplyDelete
    Replies
    1. If you are using fee schedules and want to see the difference between what was charged on the ledger (fee schedule) and your full fees then you can use the Utilization Report for Dental Insurance. If you are not using fee schedules then you will just use the Adjustment Report.

      Hope this helps.
      Dayna

      Delete
  57. When patient has use the full maximum allowed by insurance but still needs treatment, what fee should be charged Fee schedule or UCR, being the Dr in network with the insurance. Thank you

    ReplyDelete
    Replies
    1. You will need to check with the insurance plan contract. Some contracts allow you to charge full fee after a patient has met their max and some contracts do not. There is no blanket answer to your question.

      Hope this helps,
      Dayna

      Delete
  58. After insurance is maxed out does the patient pays fee schedule or ucr? Thank yoy

    ReplyDelete
    Replies
    1. You will need to check with your contract to see if you are allowed to charge full fee or stay with the fee schedule. I have not seen very many contracts that allow you to charge full fee. There is not a straight across rule on this question.

      Hope this helps
      Dayna

      Delete
  59. Thank you! And when getting the Breakdown of benefit, if I ask the representative, will they be able to tell me?

    ReplyDelete
  60. Got a question for you...Why does an in network insurance company pay more than the "Contracted Amount?" Example, Anthem Contracted amount was $70 but they paid an "Allowed Amount" of $95? What's the difference between a contracted amount and an allowed amount and why do some Anthem (for example) plans pay the contracted fee and other plans pay the allowed fee?

    ReplyDelete
  61. That's a great question. The only thing I can think of is that you sent the claim in with your full fee and they allowed a higher fee. If this is not the case then I am baffled. You could pose this question to the Insurance Editor for DPR, Teresa Duncan.

    Thank you,

    ReplyDelete
  62. If we are in-network with a patient's insurance, but implants are not a covered benefit of their plan... Do we still charge that insurance's fee or can we charge our own office fee for that procedure since it is not a covered benefit?? Thanks!

    ReplyDelete
  63. We are in network with a patient's insurance, but implants are not a covered benefit on their plan. Do we still have to charge that insurances fee for implants, or can we charge our own office fees since it is not a covered benefit anyway? Thanks!

    ReplyDelete
    Replies
    1. It depends on how your contract reads. You will always want to go by what your contract states. If you are allowed to charge a higher fee for a procedure that is not covered you can edit it at the time of treatment planning.

      Always make sure you are billing full fee to the insurance company.

      Hope this helps,
      Dayna

      Delete
  64. What if the patient has dual coverage, the primary has a higher fee. Should I write off based on the secondary's fee? I'm just wondering because when the patient only had the secondary insurance she was paying less copay?

    ReplyDelete
    Replies
    1. The rule of thumb is that the patient will only pay up to the lowest contracted fee and the office is allowed to collect up to the full office fee. So in this case you may have to write off down to the secondary but without seeing the EOB I cannot know for sure.

      Hope this helps.
      Dayna

      Delete
  65. Hello,
    I have a question I can not seem to find the correct answer to? I apologize if it has been answered above.

    If we are contracted with both PPO insurance companies and we submit to primary using their fees (which are higher than secondary),then i submit to secondary and they are contracted at a lower fee schedule, do i write off the remaining? There is a balance on the patient's account because secondary will only pay up to their contracted fees.

    ReplyDelete
  66. Yes, you are correct. The patient is only responsible for the lower of the two fee schedules. Make sure you are always sending full fee to the insurance companies if you are using fee schedules.

    Hope this helps,
    Dayna

    ReplyDelete
  67. Hi Do you have a formula for figuring out copays when downgrades and deductibles are considered?

    ReplyDelete
    Replies
    1. Yes, I recommend using fee schedules along with the Payment Table for posterior composite downgrades. When you use fee schedules, however do not use the Payment Table for everything. Search my blog for other articles about using the Payment Table and you will read more information.
      Thank you,
      Dayna

      Delete
  68. Hi when we are in network with both prim insurance and 2nd insurance but prim ins. fees are higher can i charge pt difference to primary (or higher fees)? 2nd insurance paid like they normally would but due to the different in fees there is still a balance.

    ReplyDelete
    Replies
    1. No, if you are contracted with both plans you need to honor both fee schedules. You can collect up to your full fee from the insurance plans, but only collect up to the lowest of the two contracted fees from the patient.

      Make sure you are sending your full office fee on the claim to both primary and secondary and this will reduce the amount of write offs you have.

      Hope this helps.
      Dayna

      Delete
  69. I would suggest you go to the ADA website. The answer is -the patient has the benefit of the lower allowable per line item(not Primary vs Secondary). Post your whole Fee, file to
    primary, then after Primary payment file the secondary, make adjustments considering, frequency limits, non-covered services and the like.

    ReplyDelete
    Replies
    1. Yes, that is exactly what I said. The office will collect the lowest fee from the patient. When you send full fee to the insurance company the office has the right to collect from the insurance plans up to full UCR.

      Hope this helps,
      Dayna

      Delete
  70. Hi, I have a question. When dealing with out of network benefits , is it legal to honor the patients ppo fees/copay? If so, how does it need to reflect in the ledger? In terms of audits.

    ReplyDelete
    Replies
    1. Hello, When you say "honor the patients PPO fees/copay" do you mean write off the difference?

      If you have a patient who is out of network with an insurance company and you write off the difference so the patient does not have a balance this is considered "Copay forgiveness" and it is a form of insurance fraud unless you report it to the insurance company on the claim.

      Hope this helps,
      Dayna

      Delete
  71. Being PPO with both insurances, it is confusing what to write off and what to bill to the patient. here is an example of a recent situation. billed amount 997, primary paid 295 secondary paid 396. primary w/off s/b 407 secondary w/off s/b 192. should we give a discount of 306 because of primary discount or use the secondary discount 192 and bill the patient 114?

    ReplyDelete
    Replies
    1. Hello Emily, it is a little confusing but simplified if you remember this one sentence.

      "The patient will only pay up to the lowest of the two fee schedules, however the office is allowed to collect from the insurance companies up to the office full UCR fee."

      In your example you need to know what the allowed fee is for each insurance company to figure out if the patient will owe anything. I know for sure you do not take the $407 write off because then the account will end up in a credit and the patient does not receive a credit balance. My gut is saying that you will take the $306.

      Hope this helps,
      Dayna

      Delete