The Billing Cycle€¢ The Role of the PC and LPC in the Billing Cycle • Basic Understanding of...

Confidential & Proprietary ImmediaDent 6.13

Billing 101

2 Billing 101 Confidential & Proprietary ImmediaDent 06.13

Objectives:

After reading Billing 101, you should understand the following:

• The Role of the PC and LPC in the Billing Cycle • Basic Understanding of the Billing Cycle • Information needed to Set-up the Patient Profile • Basic Insurance and Billing Terminology • How to Ensure Billing Accuracy throughout the Patient Cycle • The Cycle of a Claim and the Impact of Input Errors • Insurance set up in QSI

o How to Complete the Responsible Party Billing Information Screen o How to Add Insurance Information to the Patient Account o How to Remove an Insurance Plan from a Patient Account o Adding a Private Insurance Plan

• Basic Insurance Plan Terminology • How to Ensure Treatment Plan Accuracy • The Basics of Collecting Payment • The Patient Checkout Process • Ensuring Completed Treatment Accuracy • The Basics of Billing Prosthetics • How to Prepare Claims to be sent to Home Office • The NEA FastAttach Process • The Prior Authorization Process

Introduction:

Did you know that every patient encounter will result in a transaction? Whether the patient pays anything out-of-pocket or their insurance covers 100% of the amount due, a financial transaction will be processed. Each patient encounter has a cycle, starting with patient intake and ending with payment. The cycle may begin and end in one day or it can take several days to complete.


The Role of the LPC and PC in the Billing Cycle:

Lead Patient Coordinator (LPC) - The lead patient coordinator is responsible for overall patient care, operational flow and practice management. The LPC is responsible for gaining patient acceptance of treatment plans prescribed by doctors. The LPC must ensure that 100% of patient responsibility is collected at the time of service and overall collections in the practice are at least 92% or higher. In order to ensure positive collection rates the LPC must ensure the accuracy of patient accounts, treatment plans, insurance breakdowns and daily collection of the patient’s financial responsibility.

Patient Coordinator (PC) – The PC is the primary person responsible for scheduling, which affects practice flow, verifying insurance and ensuring the accuracy of patient information entered and maintained into the patient’s account.


Information needed to Set-up the Patient Profile:

The billing cycle begins with the PC. The PC should greet the patient and ask for their photo ID and Insurance card. The PC will then scan the front and back of both cards and return them to the patient.

*Important! - The back of the card contains key billing and insurance company contact information. It is very important to obtain a clear scan of both sides of the card for future reference. The back of the insurance card is where we find the information on contacting the insurance company to receive the benefit breakdown for new patients and to verify active coverage on every date of service if they are not an insurance active on Real Time Eligibility.

The next step of the PC’s responsibilities is to obtain the patient’s insurance information and set up the Dental Insurance section of the patient profile. There are several important pieces of information on the card that will be helpful to understand. Each card may be formatted differently, as you will notice in the examples above, but learning the true meaning of the terminology will assist you in getting the correct information entered into the patient profile. Here are some helpful definitions.


Basic Insurance Terminology:

(Refer to the glossary at the end of this document for a summary of all terminology covered)

Plan Holder - The plan holder is normally the company that is providing the dental benefit to their employees. A plan holder may have more than one plan depending on the varying levels of benefits they offer. Therefore, you may find multiple plan numbers associated with one employer.

Subscriber- This is usually the employee, or the person who is subscribing (purchasing) the dental benefits. You will use this name when setting up the subscriber information screen in QSI. *IMPORTANT: The “subscriber” may not be the patient being seen for treatment. The patient may be a “dependent” of the “subscriber.”

Dependents-this term is used to identify those individuals that are covered under the subscriber’s plan, typically the subscriber’s spouse and/or children.

Member Number - You may hear this being called multiple things. You may hear member ID/number or Subscriber ID/number. All of these are the same and need to be input into the patient’s profile in QSI. The member number is used by both the insurance carrier and provider to identify each specific subscriber’s plan. Each number is unique. The member number should be shown in the subscriber information section of the insurance screen by inputting it into the SSN/SubID field. Some insurance carriers will provide a specific unique numeric identifier as the member number, while others will use the patient’s Social Security Number.

Group #, Group ID, or Plan #- this is the number used when identifying to which insurance plan the patient is enrolled. The group number is specific to the employer’s plan type. Each group number is unique to a single employer. You will use this number to search for the correct group in the system. You may also use part of the number to search for a group. The system will return a list for you to choose from. If your search produces no results, use the entire number to set up a new group. It is very important to use the entire number including any dashes etc., just as it appears on the card. There should be only one instance of a unique group number in our system. If there is more someone has made a mistake and you should always choose the number that looks as it appears on the card.

PPO- stands for Preferred Provider Organization and means that the patient is able to be seen by a provider of their choice. Those providers that participate with the insurance agree to see the patient at a discounted rate and are deemed to be “in-network.” Sometimes “PPO” will be noted on the patient’s insurance card, but this is not always the case. If not listed on the insurance card, you will obtain this information through a verification fax-back or during discussions with the insurer. You can find a list of our in-network insurance carriers on our website.

DMO, HMO, DHMO-a DMO, HMO or DHMO plan typically selects the provider for the patient. The patient is then required to only see pre-selected providers/Dentists. If we do not participate with these plans, the patient can still be seen at ImediaDent, but will not have any insurance coverage and will be seen as a “cash” patient. Sometimes “DMO,” “HMO,” or “DHMO” will be noted on the patient’s insurance card, but this is not always the case. If not listed on the insurance card, you will obtain this information through a verification fax-back or during discussions with the insurer.


Ensuring Billing Accuracy throughout the Patient Cycle:

Each patient visit has a cycle, starting with patient arrival and ending with payment. The cycle may begin and end in one day or it can take several days to complete.

PC greets patient and gathers IDs. PC creates or updates patient account information, including an accurate

and up-to-date insurance profile

Patient is seen by the Dentist for treatment. A

comprehensive treatment plan is created by the clinical

team

LPC reviews the treatment plan and works with patient

to gain acceptance and presents options for

payment.

Upon completion of the Tx, the LPC reviews completed Tx for accuracy, ensures patient balance collected is

correct, posts current payment & creates walkout statement. After

Pt. is checked out, LPC creates necessary attachments & enters any notations needed for billing.

Claim is reviewed by the home office. Any notations for

attachments and PA's are updated on the claim and it is

then submitted to the insurance company.

Insurance company reviews claim and all necessary

attachments. Claim is then paid or denied.

Claim payment is sent to the Home Office where payment is posted to the account and any

unpaid items are either billed to the patient or corrected and resubmitted to the insurance

company.


Insurance Set-up:

The cycle of a claim begins with the PC. Once the PC has the patient’s ID’s, the patient is sent to the kiosk to fill out their paperwork (if they haven’t yet completed their online registration). While the patient is inputting their information, verify the patient’s benefits using the information from their insurance card. When the patient has completed entry at the kiosk, the PC will pull up their online registration in QSI and verify that the information entered by the patient is complete and correct. The PC will also add other needed information to the account and connect the account to the patient’s insurance plan.

The above image is the patient information screen in the patient account. There are several areas in this screen that need to be verified or entered. This screen holds many important pieces of information. This information is used by the insurance company to verify the patient and link them to their insurance plan.


SSN-the patient’s social security number is used to identify the patient. Some insurance plans do not have a specific ID; the social security # is used in these circumstances to identify the patient. The social security number should always be entered in addition to the insurance plan ID.

Rel to Resp-relationship to responsible party is used to identify the relationship of the patient to the person who is financially responsible for the account. Think of it as the person who is responsible for paying the patient’s bills. This could be the patient or some other person. It does not have to be the subscriber on the insurance. When selecting this category your choices will be self, spouse, child, other or none. *Ensure this is selected correctly.

Student- input the patient’s student status. The selections are NO, Full Time or Part Time. *Ensure this is selected correctly. Some plans may require the response for patients over 18 years of age.

Medi ID-this is the Medicaid ID number field. If the patient is covered under Medicaid, input the patient’s Medicaid ID number from their Medicaid card.

Fee Schedule-in this field we select the practice in which the new patient will be seen. By selecting the correct practice we are attaching the fee schedule for this particular practice and will only be used as the default. Fees can vary between our practices as they are determined by zip code.


The Responsible Party:

The Responsible Party is the individual who is financially responsible for the account. This is not always the subscriber on the insurance. The responsible party may be attached to several patients at multiple practices, like family members. It is important to ensure the correct person is listed as the responsible party so we can provide them with one billing statement. Each responsible party will be sent a consolidated statement for any balances due.

The information in the Responsible Party/Billing Information Screen is very critical to be accurate as this is where the patient statements will be sent. The billing department will use this information to bill the Responsible Party, or to provide to the collection agency should they not pay any remaining balances due after final adjudication of the claims.

Resp. Party Type- Above you will see an example of the options in the Responsible Party Type box. This area is where we select the type of coverage that the patient has. Here we see that the options are Cash, Collection, Dual Insurance, Discount Plan, Insurance, Medicaid and Needs Update. At ImmediaDent we use Cash, Dual Insurance, Insurance and Medicaid. Only the billing department will use the “Collection” and “Needs Update” options. If you have an existing account that you see has been indicated as Needs Update it is critical to obtain updated information for the responsible party. Most often contact by mail or phone has failed or been returned.


Adding Insurance Information to the Patient Account:

Once we have verified the information in the Patient Information Screen and the Responsibility Party Screen, we can add the Insurance information to the account. To begin this process you will need to click on Primary under the Dental Insurance section of the patient account.

Clicking on Primary will open up the Dental Insurance section. The first thing you will need to do is to enter the group number shown on the insurance card. The best practice is to enter part of the number to get a list to choose from. Too much might return no results, if someone did not enter all dashes or all numbers correctly. You might try a few attempts before continuing to add the plan, unless the patient has Medicaid.

If the patient has a Medicaid or Managed Care Organization, enter the word ‘Medi’ or ‘Medicaid’ (it doesn’t matter which you use.) After you have entered this information you will select ‘Group #,’ and ‘All Insurance Plans’ and then click on the search button. The results of your search will provide a list of Medicaid plans. You will then highlight the plan that applies to this patient and then click select. Please see the example below.

Before moving on lets go over some definitions that you will benefit from understanding.


Medicaid- Medicaid is a state-funded insurance program. Each state may manage their programs differently. These programs are designed to provide interim insurance or provide coverage for individuals who are unable to afford insurance on their own. It is very important to verify active coverage on each date of service.

Medicaid programs have restricted coverage. It is very important to understand your state Medicaid guidelines and procedures routinely covered, procedures covered only with a prior authorization, or if there are limitations on the particular plan. For example, some states have Emergency Only and Pregnancy Only coverage, which further limits the procedures that can be performed.

Managed Care Organization- Managed Care Organizations or MCOs, are Medicaid programs that are managed or administered by a third party that the state has approved. The plans are structured similarly in terms of the coverage for the patient. Some states have several MCO's. Each MCO may have small differences, so it is important to understand the particulars of each MCO, not just Medicaid. You will gain more specific knowledge in other training materials.


Completing the Plan Information Screen:

Now that we have selected the correct Medicaid plan for the patient, the Plan Information Section of the Screen will look like this for a patient that has Medicaid or an MCO.

THIS SCREEN IS ESSENTIAL TO FIRST TIME CLAIM ACCEPTANCE!

It is very important that the correct plan is selected. Always double check that the plan you have selected is correct. If you are in an MCO state, make sure that if the patient has been assigned to an MCO and that you have selected the correct MCO, not just “Medicaid.”

Once you see this screen, you will need to verify that the SSN/SUB ID contains the correct information. If the patient has Medicaid or an MCO, the entry made in the MediID field of the Patient Informations screen will need to match what is entered in the SSN/SubID field of the Insurance Plan Subscriber section (shown above). Always enter the patient’s Member/Subscriber # in both of these fields so that they match for both Medicaid and MCO plans. You can determine if the patient has been assigned to a MCO when verifying their insurance eligibility.

You will need to make sure that all contact information and patient information entered is correct.

Example:

• Medicaid: o Member/Subscriber # should match between what is entered in the MediID field and the SSN/SubID

field. • MCO:

o MCO Member/Subscriber # should match between what is enetered in the MediID field and the SSN/SubID field.

*Warning* Medicaid coverage is always for an individual. Medicaid does not have a “Family Plan.” This means that a child will have his/her own Medicaid #. This causes frequent errors when parents complete the online registration for their child. The Patient Relationship to Subscriber for Medicaid patients will always be “Self” because they have their own Medicaid number. Ensure that you verify the Patient Relationship to Subscriber, the Subscriber Sex, etc. Having any of these item incorrectly reflected will automatically result in denial of the insurance claim.


Overview:

• The Subscriber on a Medicaid Plan is always the patient because each Medicaid Pt. has their own Medicaid ID # • The Responsible Party is still based upon who is financially responsible for the patient (Ex. Parent) • The Relationship to Responsible Party depends based upon the patient’s relationship to the person shown as

being financially responsible for them (Ex. Child)

Removing an Insurance Plan (Medicaid or Private Ins.) from a Patient Account:

There are instances where a Medicaid patient or patient with private insurance will lose coverage. When this occurs, you will remove the insurance plan form the patient account. Follow the step shown below to remove an insurance

plan from a patient’s account:

****To remove an insurance plan, change the Patient Relationship to Subscriber to ‘none’ and save. This will remove the insurance plan from the patient account.

Adding a Private Insurance Plan:

The process for connecting a private insurance plan to the patient account is slightly different than the Medicaid process. You may or may not find the group number for the plan on your card. You can search for the group utilizing the same process as Medicaid except in the group number field you will want to input the beginning of your group number from your card. It is best to only input the digits before a dash or other symbol/character.

By doing this, you are able to broaden your search results as the system will attempt to provide a direct match to everything you enter. If you are entering the full group number and they have used a partial or didn't use characters, like dashes, it will not return the result and you will set up a group that already exists. When your search produces a match, the system will return a list. If your group is there with all of the numbers, even if missing characters, like dashes, please use the existing group and do not set up a new group to show the characters correctly. Setting up a new group just adds duplicates. If your search produces a match, but it contains fewer numbers, do not use this group as some employers have different benefit limits based on the trailing digits on their plan. You cannot be certain this is the exact same plan with the exact same benefit limits if there are any digits missing. If your plan exists, you will select it and save just like you just learned for Medicaid plans.

You will now update the subscriber information section. All the information needs to match the subscriber information on the insurance card for private insurance. The information in this section may or may not be the patient’s.

*Warning* If the subscriber is not also the patient, you will need to ensure that you obtain and provide the correct subscriber’s DOB, Gender/Sex – not the patient’s. Failure to do this correctly will result in the claim not being paid and can even cause the claim to get lost in cyber-space.


If you are selecting a pre-set group, be sure to review the benefit limits that are in the system and confirm they match your benefit breakdown.

When your search does not return a result for a private insurance plan, this means that the group does not yet exist. You will need to follow these steps to create the plan.

After you have searched the group number you will need to close the search results box (as shown below) that has indicated that there are no results found. You will then select ‘Add Ins. Plan’

Below is the example of the screen you will need to complete:


The instructions to complete this screen are detailed in both QSI training modules and on InfoSource, so we will not detail them here. However, we will cover some terminology and main points that most often lead to mistakes. This information will be helpful to understand and make more sense when you complete your QSI training modules.

*Warning* - NEVER add a carrier to the system! If you can't locate the correct carrier or if you have any question as to whether the carrier displayed in search results is correct, select the carrier that reads, “Call Samson for Carrier Set up.” This should only happen with more obscure insurance carriers. If you select “Call Samson for Carrier Set up,” the treatment plan will calculate using UCR out-of-network cash fees, as this is the default fee schedule for “Call Samson for Carrier Set up.” Never use this for a common in-network carrier as the appropriate fee schedule needs to be attached and it won’t be if you use the above option.

The Carrier drives the fees. If you do not select the correct carrier, the treatment plan will not calculate correctly, resulting in inaccurate estimates being provided to the patient. All in-Network insurance plans are pre-loaded. You should never need to use this for any of the carriers that are in-network with ImmediaDent. Do not get hung-up on attempting to match a claim mailing address or the Payer ID. We use a clearing house and they may use a different number in our system, which will route to the correct Payer ID when the claim is submitted. When billing electronically the address is not important.

Trust the list and make your best guess on the more commonplace in-network insurance carriers, like Delta Dental, Anthem, Guardian, etc. These are examples of In-network insurance carriers and you need select the correct in-network carrier to quote estimated treatment correctly. The billing department will re-route the claim and make corrections if you selected the wrong choice. By doing this, you will have, at minimum, estimated the cost to the patient at in-network fees and there should be only minimal differences in fees.

Below is an example of the Carrier drop down:


Plan design- The employer designs and offers a plan to their employees (subscribers). The employer determines the (group) plan maximum, deductibles and the coverage limits. Each group insurance plan can be different, even though the carrier is the same. It’s important to remember that the Plan is managed by the employer, not the insurance carrier. The carrier only manages the payments and accounting for the plan. Plan designs can change from year to year, normally at the beginning of the new plan year. Plan years can begin in any month, but most plan years begin in January.

When you are setting up an insurance plan (not to be confused with setting up an insurance carrier as this is not done at the practice level), there are several pieces of information that are required in order for the patient and the insurance to be billed correctly. The first screen is the plan limits and deductibles. It is very important to enter this information correctly as the system uses this to calculate the treatment plan. What you put here will update the patient’s insurance screen when you attach the group. If you set up a new "Plan" with a new "group number" you will be setting up the entire company’s group plan. If another patient from this employer comes into one of our practices and presents an insurance card with the same "group number," they will attach the information that you are entering to set up this "group" or employer plan, so it is important to do this accurately.

You can obtain a breakdown of the patient’s plan benefits when a fax-back is received from the insurance carrier or by printing a detail of the plan benefits directly from the carrier’s web portal. Use the information obtained from the benefit breakdown or fax-back received to complete the benefit breakdown.

Above you will see the first screen that asks you to enter the deductible and maximum information. Make sure you put special notes in the “Plan Notes” section. An example of a note here would be that the plan downgrades composite to amalgam on posterior teeth. Some plans will have no exceptions, while some will have various. You will want to note them as it helps communicate to the patient. You will also need to edit your treatment plan estimates with the known information.

Once the information is entered you will select ‘Coverage’ at the bottom right of the screen.

Step 3 of the Insurance Plan set up process in QSI provides information about the plan coverage breakdown. This screen also is used by the system to calculate the treatment plan estimate. Most all plan coverage breakdowns obtained will provide enough detail to complete this screen. However, if your breakdown does not provide the necessary detail to complete this set up, use the default standard percentages and deductibles automatically added by the system.


Some tips on this screen:

Ded. Waived - Insurance plans frequently have deductibles, but not all of them do. Additionally, plans with deductibles may waive them for certain procedures. It is common for the deductible to not apply to preventative care, as shown below and indicated by the default checkmarks automatically selected for you. The benefit breakdown/inquiry will generally indicate if the deductible is applicable to certain procedure types and when it is waived. Click on the “Ded. Waived” selection box to display a check mark when the deductible does not apply.

Percent - This is where you will enter the % of the fee that is covered by insurance. Again, you will find this on your benefit breakdown. Make certain you have updated these to match your benefit breakdown. The system uses these percentages to estimate the patient’s responsibility in the treatment plan. If you do not have these set correctly the system will produce an inaccurate estimate that will be shared with the patient. Our goal is to always try to provide the "Best Estimate" based on our current knowledge of the patient’s plan.

After completing step 3, you may progress to step 4 of the Insurance Plan Set up by clicking the “Fee Schedule” button.

This is the last screen of the insurance plan set up. There are no selections that need to be made on this screen, you will simply click ‘Save’ and your plan will be completed.

Now that we have created the account, we can update the status of the patient on the schedule to “R” as the patient is now ready to be seen by the clinical staff.

Please visit InfoSource to obtain more information on these processes and for step-by-step instructions


Insurance Plan Set up Terminology: (Refer to the glossary at the end of this document for a summary of all terminology covered)

Deductible- Deductible is a term that refers to the amount the patient must pay upfront before their insurance plan will cover the services performed. A deductible usually ranges between $50.00 and $200.00 and generally applies per individual covered under the plan. The patient is responsible to satisfy the deductible during each coverage year or policy period before insurance will respond/pay.

Family Deductible- A family deductible is the maximum of combined deductibles for all participants in family. Individual deductibles are applied until the family deductible has been met. All individual deductibles are satisfied when a family deductible is met.

Example:

• There are 4 family members covered by an insurance plan o Each individual deductible is $50.00 o Family deductible is $150.00

• Three family members pay their $50.00 deductible, satisfying the family deductible • The fourth family member’s individual deductible will now be $0 for the remainder of the current insurance plan

policy period.

The deductibles paid by individual members of the family should not exceed the amount of the family’s deductible. This will only calculate correctly in QSI if our accounts are set up correctly and all family members are linked through the Responsible Party.

Maximum- Insurance policies dictate a maximum amount the policy will pay within a given policy period/year. This generally ranges from $500-$2000 for most company dental plans. This means that the insurance will pay this amount to a patient’s dental provider(s) over the course of the coverage year, subject to deductibles and other limitations. The system resets each plan year to start over with the current plan year maximum. If they have used some of their benefits with a previous dentist, you will need to reflect this in the insurance screen of the patient’s profile. QSI can make calculations, but it does so using values that are entered into the system. Not starting with the correct values in the patient’s insurance screen will cause their benefits to be applied incorrectly. This results in miss-calculated treatment plan estimates and an overstated amount of insurance coverage. A statement will be generated and mailed to the patient for the unpaid balance on their account. When presenting treatment plans to a patient, be sure to always communicate that we provide our best “Estimate" of their treatment cost based upon what we know today.

Deductible Waived- The deductible does not always apply to all procedures. There are certain types of procedures that will not require the patient to pay the deductible. These procedures are typically preventative in nature. You may see this as ‘deductible waived,’ or ‘deductible does not apply.’


Insurance Plan Set up Terminology (Continued):


Fee Schedule- Each Carrier has a standard fee that is specific to each procedure. These fees are entered into QSI and attached to the carrier by the Accounting Department. It is not necessary to select a fee schedule in the creation of the plan because the fees are connected to the Carrier and will automatically be associated once the Carrier has been chosen.

UCR- Refers to the fees that have been selected for each procedure by the Accounting Department. The UCR fee is the rate that a cash patient will pay. UCR stands for Usual and Customary Rates.

Restorative- Restorative service types are those that restore the tooth to its original structure. Examples of these types of services are fillings, bridges and crowns.

Prosthetics- Services of this type use an artificial prosthesis to help restore the functionality of missing teeth. Examples of these types of services are dentures, partial dentures and implants.

Endodontic (Endo) - Services of this type are used to save the tooth and generally deal with the root of the tooth. Root canals are an example of these services.

Periodontics (Perio) - Services of this type are related to treating gum disease. Examples of this type of service are scaling and root planing, splinting and full mouth debridement.

Oral Surgery- Refers to services that are done surgically. Examples of this type of service are extractions and other types of removals as well as treatment done to the bone and sinuses.

Preventative- Service types are those that are done to identify and prevent problems. Examples of these types of services are examinations, cleaning (prophy) and fluoride. Most insurance plans will pay 100% of preventative service without a patient deductible.

Basic- Basic services refer to restorative procedures. Sometimes Endo, Perio and Oral Surgery are also considered a “basic” service. Though not in our system, you may see these terms used in a verification of benefits. Many insurance plans pay 80% of basic services, generally after a deductible has been met.

Major-Major services typically refer to Prosthetic services. Sometimes Endo, Perio and Oral Surgery are also considered major. This is determined by the insurance carrier. Though not in our system, you may see these terms used in a verification of benefits. Many insurance plans pay 50% of major services, generally after a deductible has been met.


Ensuring Treatment Plan Accuracy:

After the patient’s examination, the Doctor will create a treatment plan that will be entered into QSI and reviewed with the patient by the LPC. Not only is the LPC responsible for presenting the treatment plan, but they are also responsible for ensuring its accuracy. Ensuring the accuracy of a treatment plan estimate will require that the LPC review the patient’s set-up and treatment plan prior to presenting it to them. The LPC should also ensure that the patient’s insurance is set-up properly.


The following related step-by-step instructions are available on InfoSource:

• Treatment Plan Processes in QSI

• Treatment Plan Acceptance Scripting

• CareCredit

• ImmediaDent Payment Plan

• Using ITerminal to process payments

• Telecheck


The Basics of Collecting Payment:

Payment should be collected after the patient has accepted the treatment presented but before any work begins. Once payment arrangements have been made, the clinical staff should be made aware that dental work may begin. After the patient’s treatment is completed, the last step will be to check them out.

The Patient Checkout Process:

Every patient should receive the following items as a part of the checkout process:

• Receipt folder • An appointment card for their next visit • A walkout statement detailing items from their visit • A receipt of any payments made • CareCredit paperwork, when applicable • Any additional paperwork (treatment plan, interrupted services policy, etc.)

A good recommendation is to collect as many of these things for the patient while they are having their treatment completed. When the patient has completed treatment and is brought to the front, we can add the paperwork that cannot be prepared in advance, like their receipt, walkout statement and appointment card.

It is important that we schedule the patient for the next appointment while they are in the practice. If the patient is unable to schedule, we should still include an appointment card in their walkout folder. If an appointment is not scheduled, please write “Please call to schedule your next appointment” on the appointment line.



• Financial Transactions and Walkout Procedures


Ensuring the Accuracy of Completed Treatment: Once the patient has left and their visit has been completed, the LPC needs to review the procedures that were posted. The LPC should verify that the procedures planned for treatment were, in fact, completed and the billing is accurate.

The Basics of Billing Prosthetics:

We should make sure that we are billing things when appropriate. For example, prosthetics should only be billed on the SEAT DATE. If a crown was billed on the preparation date, it will need to be corrected.

Preparing Claims to be sent by Home Office:

The LPC will need to create an attachment or enter a prior authorization number to ensure that the claim is ready for payment. During the review process the LPC should take this time to verify that the billing information is accurate in the account. We should verify that the ID numbers and insurance information is correct.

NEA FastAttach:

Because the Billing Department sends all claims on behalf of ImmediaDent practices, you will need to “prepare” the claim to be sent, which may require charting or X-rays to be sent with the claim. The software tool that we use when attaching perio charting, radiographs (X-rays) and any narrative for a claim is called NEA FastAttach. NEA allows us to take a screen shot of our attachment and then assigns a reference number it. Once you have the reference number you will need to follow the steps outlined in InfoSource to electronically associate any attachments with the claim.



• NEA FastAttach


Prior Authorizations:

We are in-network with many different carriers, including some state-funded plans. Though many carriers recommend a pre-treatment estimate, state-funded services often require that a prior authorization is completed before treatment may be performed.

A prior authorization is an approval for treatment that is obtained before treatment is started. The turn-around time for the prior authorization process can be up to 3-weeks or even more. Because of this, it is important to ensure that you have received a prior authorization, when required, prior to the patient’s arrival for their scheduled treatment and ALWAYS before treatment is started. The procedures for which prior authorizations are required vary based upon the internal needs/requirements of the state-funded insurer. This is why it is important to know and understand the limitations of a patients’ insurance plan.

When a prior authorization is approved, the number for that approval needs to be entered into the line of service for which the authorization is required.

Some items that may require prior authorization are:

• Dentures • Partial Dentures • Crowns • Root Canals • Periodontal Scaling and Root Planing • Some surgical procedures



• Prior Authorizations


Glossary:

Basic- Basic services refer to restorative procedures. Sometimes Endo, Perio and Oral Surgery are also considered a “basic” service. Though not in our system, you may see these terms used in a verification of benefits. Many insurance plans pay 80% of basic services, generally after a deductible has been met.

Deductible- Deductible is a term that refers to the amount the patient must pay upfront before their insurance plan will cover the services performed. A deductible usually ranges between $50.00 and $200.00 and generally applies per individual covered under the plan. The patient is responsible to satisfy the deductible during each coverage year or policy period before insurance will respond/pay.

Deductible Waived- The deductible does not always apply to all procedures. There are certain types of procedures that will not require the patient to pay the deductible. These procedures are typically preventative in nature. You may see this as ‘deductible waived,’ or ‘deductible does not apply.’

Dependents- This term is used to identify those individuals that are covered under the subscriber’s plan, typically the subscriber’s spouse and/or children.

DMO, HMO, DHMO- A DMO, HMO or DHMO plan typically selects the provider for the patient. The patient is then required to only see pre-selected providers/Dentists. If we do not participate with these plans, the patient can still be seen at ImediaDent, but will not have any insurance coverage and will be seen as a “cash” patient. Sometimes “DMO,” “HMO,” or “DHMO” will be noted on the patient’s insurance card, but this is not always the case. If not listed on the insurance card, you will obtain this information through a verification fax-back or during discussions with the insurer.

Endodontic (Endo) - Services of this type are used to save the tooth and generally deal with the root of the tooth. Root canals are an example of these services.

Fee Schedule- Each Carrier has a standard fee that is specific to each procedure. These fees are entered into QSI and attached to the carrier by the Accounting Department. It is not necessary to select a fee schedule in the creation of the plan because the fees are connected to the Carrier and will automatically be associated once the Carrier has been chosen.

Fee Schedule field- In this field we select the practice in which the new patient will be seen. By selecting the correct practice, we are attaching the fee schedule for this particular practice and will only be used as the default. Fees can vary between our practices as they are determined by zip code.

Group #, Group ID, or Plan #- This is the number used when identifying to which insurance plan the patient is enrolled. The group number is specific to the employer’s plan type. Each group number is unique to a single employer. You will use this number to search for the correct group in the system. You may also use part of the number to search for a group. The system will return a list for you to choose from. If your search produces no results, use the entire number to set up a new group. It is very important to use the entire number including any dashes, etc., just as it appears on the card. There should be only one instance of a unique group number in our system. If there is more, someone has made a mistake and you should always choose the number that looks as it appears on the card.

Major- Major services typically refer to Prosthetic services. Sometimes Endo, Perio and Oral Surgery are also considered major. This is determined by the insurance carrier. Though not in our system, you may see these terms used in a verification of benefits. Many insurance plans pay 50% of major services, generally after a deductible has been met.


Managed Care Organization- Managed Care Organizations or MCOs, are Medicaid programs that are managed or administered by a third party that the state has approved. The plans are structured similarly in terms of the coverage for the patient. Some states have several MCO's. Each MCO may have small differences, so it is important to understand the particulars of each MCO, not just Medicaid.

Maximum- Insurance policies dictate a maximum amount the policy will pay for within a given policy period/year. This generally ranges from $500-$2000 for most company dental plans. This means that the insurance will pay this amount to a patient’s dental provider(s) over the course of the coverage year, subject to deductibles and other limitations. The system resets each plan year to start over with the current plan year maximum. If they have used some of their benefits with a previous dentist, you will need to reflect this in the insurance screen of the patient’s profile. QSI can make calculations, but it does so using values that are entered into the system. Not starting with the correct values in the patient’s insurance screen will cause their benefits to be applied incorrectly. This results in inaccurately calculated treatment plan estimates and an overstated amount of insurance coverage. A statement will be generated and mailed to the patient for the unpaid balance on their account. When presenting treatment plans to a patient, be sure to always communicate that we provide our best “Estimate" of their treatment cost based upon what we know today.

Medi ID- This is the Medicaid ID number field. If the patient is covered under Medicaid, input the patient’s Medicaid ID number from their Medicaid card.

Medicaid- Medicaid is a state-funded insurance program. Each state may manage their programs differently. These programs are designed to provide interim insurance or provide coverage for individuals who are unable to afford insurance on their own. It is very important to verify active coverage on each date of service. Medicaid programs have restricted coverage. It is very important to understand your state Medicaid guidelines and procedures routinely covered, procedures covered only with a prior authorization, or if there are limitations on the particular plan. For example, some states have Emergency Only and Pregnancy Only coverage, which further limits the procedures that can be performed.

Member Number - You may hear this being called multiple things. You may hear member ID/number or Subscriber ID/number. All of these are the same and need to be input into the patient’s profile in QSI. The member number is used by both the insurance carrier and provider to identify each specific subscriber’s plan. Each number is unique. The member number should be shown in the subscriber information section of the insurance screen by inputting it into the SSN/SubID field. Some insurance carriers will provide a specific unique numeric identifier as the member number, while others will use the patient’s Social Security Number.

Oral Surgery- Refers to services that are done surgically. Examples of this type of service are extractions, treatment done to the bone and sinuses, etc.

Periodontics (Perio) - Services of this type are related to treating gum disease. Examples of this type of service are scaling and root planing, splinting and full mouth debridement.

Plan Holder - The plan holder is normally the company that is providing the dental benefit to their employees. A plan holder may have more than one plan depending on the varying levels of benefits they offer. Therefore, you may find multiple plan numbers associated with one employer.


PPO- stands for Preferred Provider Organization and means that the patient is able to be seen by a provider of their choice. Those providers that participate with the insurance agree to see the patient at a discounted rate and are deemed to be “in-network.” Sometimes “PPO” will be noted on the patient’s insurance card, but this is not always the case. If not listed on the insurance card, you will obtain this information through a verification fax-back or during discussions with the insurer. You can find a list of our in-network insurance carriers on our website.

Preventative- Service types are those that are done to identify and prevent problems. Examples of these types of services are examinations, cleaning (prophy) and fluoride. Most insurance plans will pay 100% of preventative service without a patient deductible.

Prosthetics- Services of this type use an artificial prosthesis to help restore the functionality of missing teeth. Examples of these types of services are dentures, partial dentures and implants.

Rel to Resp-relationship to responsible party is used to identify the relationship of the patient to the person who is financially responsible for the account. Think of it as the person who is responsible for paying the patient’s bills. This could be the patient or some other person. It does not have to be the subscriber on the insurance. When selecting this category your choices will be self, spouse, child, other or none. *Ensure this is selected correctly.

Restorative- Restorative service types are those that restore the tooth to its original structure. Examples of these types of services are fillings, bridges and crowns.

SSN- The patients’ social security number is used to identify the patient. Some insurance plans do not have a specific ID; the social security # is used in these circumstances to identify the patient. The social security number should always be entered in addition to the insurance plan ID.

Student- input the patient’s student status. The selections are NO, Full Time or Part Time. *Ensure this is selected correctly. Some plans may require the response for patients over 18 years of age.

Subscriber- This is usually the employee, or the person who is subscribing (purchasing) the dental benefits. You will use this name when setting up the subscriber information screen in QSI. *IMPORTANT: The “subscriber” may not be the patient being seen for treatment. The patient may be a “dependent” of the “subscriber.”

UCR- Refers to the fees that have been selected for each procedure by the Accounting Department. The UCR fee is the rate that a cash patient will pay. UCR stands for Usual and Customary Rates.

The Billing Cycle€¢ The Role of the PC and LPC in the Billing Cycle • Basic Understanding of...

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Transcript of The Billing Cycle€¢ The Role of the PC and LPC in the Billing Cycle • Basic Understanding of...