How is the Ascend insurance estimate calculated? Why doesn't my insurance estimate look right?

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1 How is the Ascend insurance estimate calculated? Why doesn't my insurance estimate look right? Whether you re new to Dentrix Ascend or you haven t had the time to dig into the behind the scenes settings that go into calculating insurance estimates, this report will give you the answers you need. You can use this set of instructions as a reference for yourself when the insurance estimate just doesn t look right and you need to fix it. Or, you can use this report as a training tool for the other administrative team members in your practice. With this report, you ll know the places to quickly check to make sure the insurance estimate is correct, every time. Step 1 You must create a case so you can use the Treatment planner & Preview in order to see the total fee, insurance adjustments, insurance estimate and guarantor amount. You create a case in the treatment planner. If you leave the procedures as Unassigned then you will not be able to see the financial estimates. Be sure to train your clinical team to create cases. Step 2 To begin understanding the insurance estimate, the Treatment Plan Case Total fee is the office s standard fees added together. Page 1

2 Step 3 After you create your case, scan down the list of planned procedures to see if the insurance estimate makes sense. Sometimes you will find the same procedure being performed on different teeth but the insurance estimates are different. This may or may not be a problem. When you see that Primary insurance will cover $0 look at that procedure in the Progress Notes to see if it's simply clicked off Bill to Insurance. This can happen in conversions and is a super easy fix! Check this first and then rerun your treatment planner Preview to see if this fixes your concern. Here's an example why would one sealant be paid in full (tooth #2) and the other paid at $0?? Page 2

3 By going to the Progress Notes, and clicking on the procedure, we can see that Bill to Insurance is Off. Change this to On and then see if that fixes the problem. Step 4 Next, understand the deductible. Estimated deductible applied When you see this, the deductible will be applied to the PPO fee and is applied before the coverage percentage is applied. To see the deductible, go to the Patient, Insurance Information. Then click on the plan and then click on the Benefits box to bring up: Page 3

4 Look here to see that the deductible is entered correctly. Step 5 Next in understanding the insurance estimate is the Estimated write off adjustments. This is the difference between the standard fees and the PPO fees. Here is where you can find errors: 1. Is this carrier on your list of carriers/networks your office is contracted with? And is an Insurance Adjustment being calculated on the treatment plan? Most of the time when we are in-network there should be an Insurance Adjustment shown, except if the procedure is not a covered benefit or in very rare cases where our fees are equal to or below the carrier's PPO fee schedule. 2. Is the correct PPO fee schedule attached? 3. To see the PPO fees Go to Patient, Insurance info and look at the carrier & the employer. 4. Now, go to Home, Carriers and then find the carrier click on the carrier. 5. Next, find the employer and click on the employer. Look under the middle column for PPO contracted fee schedule this will show you which fee schedule is being used. Page 4

5 6. To see the individual fees, click on Settings Fee Schedules and click on the one you want, now scroll down to the fee to see the PPO used in your treatment plan. Do these look right to you? What if the fee in the treatment plan is different from the fee listed in the fee schedule? When you see this, go to the Progress notes for your patient and you may see an orange triangle, like this: Page 5

6 So the existing amount may represent an old fee (did you update your fees recently but choose not to update fees on existing treatment plans?) or a special accommodation made by the doctor. To help communicate these special circumstances on a team you can add a note into this procedure to explain why the unique fee exists. When should you update the fee to the recommended value? When there is no note explaining why this unique fee exists you could call the patient to discuss the treatment plan as a confirmation call. You could say, "Hi this is Jill with HealthPark Dentistry, I'm calling to confirm your daughter's appointment on Monday, June 15 th. -- Great! We're looking forward to seeing you. Also, I wanted to let you know that I've reviewed the treatment plan to see what our insurance estimate is and what your portion will be, do you already have a copy of this treatment plan with the insurance estimate?" If they have a copy then you do not want to update the fees. If not and they are interested in talking with you about these fees, then you could go ahead and do these updates. Another good reason to update these fees is when you see that this patient's insurance carrier is one that your dentist has joined because you will have to follow the PPO fees (allowed amount) anyway. And, you want your patient to see your standard fees. A third reason to increase fees is when you can tell the fee is just plain wrong. Let's say the fee is $5.60 and the orange triangle alert shows that the correct fee is $56 you can probably guess that somehow a mistake was made. The sealant material may cost close to $5.60! Again, I would always call & "confirm" with the patient and, in that case, even if they had a copy, I would say "When I was reviewing your treatment plan, I noticed that one of the fees was entered wrong it's actually $56 not $5.60. Now, we estimate your insurance to cover 80% but I wanted to just let you know that I changed this one fee." Often, you won't change this fee at all just like in this example. I'm not sure why 3 of the 4 sealants came up as $53 rather than the correct $56. Since it's a small amount and I don't want to risk that Mom/Dad have a copy of the treatment plan or, b/c their total treatment plan is $1004, I don't think a few dollars on sealants makes any sense to even bring up and shake their confidence in the financial / insurance management of the practice. Page 6

7 Step 6 Finally, in our understanding of the insurance estimate: Estimated insurance payment To replicate how Ascend calculates this, here is an excel spreadsheet so you can see each calculation. To create a spreadsheet for your patient to see how the insurance estimate is calculated: For each procedure code, enter in the standard and PPO fees. Use the instructions above to find the standard and PPO fees. If a deductible is to be applied, enter the deductible first, then calculate the percentages that s how to calculate the insurance payment. In my example, this is the Delta after column meaning the Delta fee after the deductible has been taken out. The last two columns show what the insurance will pay and the patient will owe. Now, looking at the totals from the columns: The estimated write off is the difference between the standard and PPO fees Obviously, it s a chunk of work to create this spreadsheet and the only reason to take the time is when you are really battling getting your insurance estimate to make sense. I worked on this spreadsheet because I just wasn t getting the right numbers and this helped me get solid on where the insurance estimate came from. This is also a great tool for training. You could assign new administrative team members an existing treatment plan case (pick a short one and a long one!) and ask them to create a spreadsheet to prove the calculations in Ascend. This will help your new team members to really understand where the numbers come from and you can feel confident that when they re working with treatment plans and talking with patients, they can dig in and verify the accuracy of the settings. Page 7

8 Step 7 Annual maximum set to $0 - One special item to check in Ascend to make sure that your insurance estimate is accurate is to make sure that the family and individual maximum is not set to $0. You also want to check to see that all the dental insurance benefits have not been used up. To check this, go to the patient and choose Insurance Info then click on the Benefits button. Look at the bottom row to see how much has been used. The red circle highlights where to look to make sure the Maximum doesn t show $0 or the Used doesn t show the full amount. This is where you would enter the benefits remaining as well as the maximums on the plan. Obviously if the patient has used up all their benefits for the year, then the insurance estimate may look wrong but it is correct. On the other hand, if the annual maximum has accidentally been entered at $0, then it will show that the insurance won t cover anything. Usually this is a mistake. Just be aware that you can check this to make sure the info is correct. Step 8 Dependent date of coverage set too late One peculiarity of Ascend is that when you add dental insurance to a dependent, the default date for coverage is the date you edit the dependent s insurance info. It does not look back at the coverage date for the subscriber (like it should). So, what can happen is that the child s insurance estimate shows $0 coverage when you know that s not right. And, you can check everything else and it s all correct, so this is another important area to check. Go to the child patient, Insurance Information and look at the coverage date make sure this date matches the date of the subscriber s. Here is Dad s info as the subscriber to insurance: Page 8

9 Here is the daughter's insurance info: You can see the Coverage Start dates are different. You need to change the daughter s coverage start date to match the Dad s and that will fix the insurance estimate. To summarize the factors that affect your insurance estimate: Your standard fee Bill to Insurance is On Your PPO fee based on the carrier and the employer The deductible The percentage coverage Remaining benefits Annual maximum Date of coverage Page 9

10 You can use this as a quick checklist to keep at your desk. So, what do you do if your insurance estimate looks wrong? Start off by checking each one of these items to see where the error may lie. To really understand your estimates, you may also want to create a spreadsheet to see if you can replicate these numbers and generate the same estimate as Ascend. If you are using this report as training, then you will create a treatment plan and spreadsheet to check your work for each of the following situations: 1. Find a patient scheduled in the next week for treatment who has insurance and print the treatment plan. Check each one of these factors listed above to make sure each one is accurate. Now create a spreadsheet to confirm how the insurance estimate was created. 2. Create a fake patient and set up the insurance information similar to this first patient. Use the same insurance carrier, employer, deductible, maximum, fee schedule, etc. a. Now, enter the same treatment plan as the first patient to make sure you get identical numbers. b. Next, choose a different PPO fee schedule and update the fees. Look at how the insurance estimate changes. c. Next, change the deductible and update the fees. How did the estimate change? d. Next, change the benefits remaining and update the fees. What do you see? e. Just for a test, enter $0 in the annual maximum box and look at the treatment plan. Did it go to $0? f. If you have the rights, can you change the percentage in the coverage table for one of the code ranges in your treatment plan? See how this changes your estimate. 3. Choose a couple more existing patients and create spreadsheets to prove how Ascend calculated their insurance estimate. Repeat this until you are confident of how this works. After you fix the errors, you may need to resend a claim. To do this, go to Ledger, click on Walkout and then click Create Claims. Conclusion When you understand how the Dentrix Ascend insurance estimates are calculated you can more confidently explain treatment to patients and collect the right amount of money. In collections, confidence in the numbers is key. By providing this training to your administrative team, and requiring each person to complete the practices before they sit at the checkout station will dramatically improve your collections because your team will quickly and easily identify errors with insurance estimates, correct them, and then collect accurately. Page 10