Do you have a tough issue in your dental office that you would like addressed? Each week the experts on Team Troubleshooter will tackle those issues and provide you with answers. Send questions to [email protected].
QUESTION: I’m a dental office manager. Our office is no longer a participating provider of one of our insurance companies. The company decided to process 50% of our claim using our old fee schedule. They claimed that some people signed up for a fee schedule-based payment, and they say that those patients are responsible for the difference.Everything I’ve read indicates insurance companies are to pay at the usual, customary, and reasonable (UCR). I strongly believe this insurance company is taking us for a ride. The company said there is no way to tell who has such a contract to use this fee schedule. They also said that they don't have a list of the employers who signed up for this contract. I told them if they know which enrollees have this fee schedule, please send me a list. They replied there's no way to send a list, no way to find out who is under this fee schedule, and no way to group or classify people. The benefits pages of the patients the company paid on with reasonable and customary fees and the patients that they paid with greatly reduced rate, look exactly the same. This can be a loss of hundreds of dollars for our practice daily. How can I fight this?
ANSWER FROM KYLE SUMMERFORD, Editor of Dental Assisting & Office Manager Digest and founder of DDSGuru:
I feel your pain. I had a similar situation occur at an office where I worked as the office manager. It took me a while to get to the bottom of things, but once I did I understood why the situation was happening. As it turned out, at one point the office had signed up with a company that negotiated fees for the practice, which in turn signed us up for negotiated contracted fees with every single dental insurance PPO plan in the book. To me it made no sense to accept these ridiculous low reimbursement rates when we would have been compensated at the UCR, which is always a higher fee.
In my case it turned out to be Dentemax. I quickly dissolved the contract with them but the payments by Aetna, Cigna, and UHC were still being paid at the contracted rates. I contacted Dentemax and explained what was happening. Apparently they couldn’t help me so I contacted each insurance company and sent them a copy of the termination of contract with Dentemax. Finally, the problem was solved.
I strongly urge you to check into any past contractual agreements you or anyone else in the office may have signed up for in the past. I hope this helps!
ANSWER FROM LAURA HATCH, founder of Front Office Rocks:
Sorry to hear you’re having issues with the insurance company. But honestly, those are everyday issues in our industry, aren’t they? First, as far as I know, there is no way to know what the allowed amount the insurance plan will pay is unless they tell you when you call to verify benefits. I’m sure you’re aware that most will not tell you. The only way you might have a chance of finding out is if you happen to get a new insurance person on the phone who doesn’t know better, but that doesn't happen often.
The best way you’ll be able to battle this issue is to start to build a fee schedule in your practice management software. As you start to receive EOBs from this particular plan, you can enter the actual payment amount in your software. (Depending on software it might be called something different, i.e., Payment Table or Coverage Book.) By entering that information, you can better predict what the insurance will pay on a procedure going forward, however, that won't help you until you know what plan the patient is on and you start to get many codes paid.
Secondly, are you still charging patients the full UCR amount of your fee? Now that you’re no longer in network for that insurance company, you don't have to follow the fee schedule for what they allow. Your office should be charging the full amount for the procedure and the patient is responsible for any balance the insurance does not pay. If you’re finding that you’re not estimating the insurance portion correctly, you might want to change the percentage covered to a lower amount so that you underestimate what you’re expecting from the insurance company rather than having to go back to the patient afterwards to collect. Good luck!
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