Top that, Webster
Show me the money!
There's a discount for that?
What if
100
refers to a provider that has a contract with an insurance plan to provide services to its plan members at a pre-negotiated rate. Because of this relationship, member pay a lower cost-sharing when you receive services from the provider.
What is In-Network
100
Where the insurance allowable amount for my location can be found
What is Ortho Fee Schedule Google Sheet
100
Standard discount percentage for PIF
What is 5%
100
What if an insurance discount was not applied during contract entry?
Correction will have to be made after contract has been realized, Submit an Revcycle Ortho KACE Ticket for additional support
200
This is the total amount insurance will pay towards any orthodontic treatment. Orthodontics is different because this acts as a piggy bank and does not replenish year to year. It is the total amount available for the duration of the insurance plan
What is Orthodontic Lifetime Maximum (LTM)
200
Non-Participating Provider
Tx Fee $6,000
Ins LTM $1,000 @ 50%
Patients responsibility: ?
Insurance responsibility:?
What is Patient responsibility: $5,000
What is Insurance responsibility: $1,000
200
Maximum discount bundle percentage
What is 10%
Example: Patient is hygienist and has a child in treatment.
Hyg discount is 50%, sibling discount is 5% - you may not combine these discounts.
Example: Patient has a sibling in treatment and is paying in full.
Sibling discount is 5%, Paid in full discount is 5% - you may combine these discounts
200
What if a patient loses coverage during treatment, do we reapply the adjustment discount from their insurance allowable fee? (commercial carriers)
If a patient has active coverage on the date their treatment begins, their fee is reflected based on in-network allowable amounts. It does not revert back if the patient loses coverage mid-treatment.
300
Some orthodontic plans require that patient wait a certain amount of time before they are able to use their benefits.
What is Waiting Period
300
Non-Participating Provider
Tx Fee $6,000
Ins LTM $3,500 @ 50%
Patients responsibility: ?
Insurance responsibility:?
What is patients responsibility: $3,000
What is insurance responsibility: $3,000
-Insurance will cover up to 50% of total treatment.
($6,000) X (.50)= $3,000
300
Mandatory discount that must be applied when applicable
What is In Network discount
It is our contractual obligation to apply in network discounts.
Additional courtesy discounts can be applied in addition to in network discount
Example: If patient has Delta Dental of AR (in-network) and has a sibling in treatment
We will honor their allowed fee schedule (apply in-network adjustment)
We will honor the 5% discount of their allowed fee schedule for the sibling discount. (apply the sibling discount)
We will honor the 5% discount of their allowed fee schedule for the Paid in Full discount. (apply the PIF discount)
300
What happens if a patient loses their insurance coverage prior to completion of treatment?
The patient will be responsible for the remaining insurance balance. PPO discount will not be reversed.
400
The maximum amount that can be charged for a procedure based on the agreement between the Participating provider and insurance carrier. This does not apply to non-participating dentists.
What is Allowable Amount (Plan, Maximum)
Reimbursement rate
400
Participating Provider
Tx Fee $6,000
Ins LTM $1,000 @ 50%
Insurance Allowable: $4,000
Patients responsibility: ?
Insurance responsibility:?
What is patients responsibility: $3,000
What is insurance responsibility: $1,000
-Tx Fee $6,000
-PPO Discount $2,000 (Tx fee $6,000) - ($4,000 Allowable)
-Est Ins (LTM) $1,000
-Pt resp $3,000 (Allowable $4,000) -(LTM $1,000)
400
Exceptions to standard Rock discounts
What is Yes!!!
* Marketing promotions
* Provider Discretion
* Medicaid DNS
400
Will the insurance allowable for my location change?
Very Likely! It is important to use the live Ortho Fee schedule document as fees do change periodically.
500
This allows two insurance carriers to determine their fair share of the cost for covered services. (Who pays first and how much)
What is Coordination of benefits
500
Participating Provider
Tx Fee $6,000
Ins LTM $3,000 @ 70%
Insurance Allowable: $3,000
Patients responsibility: ?
Insurance responsibility:?
What is patients responsibility: $900
What is insurance responsibility: $2,100
-Tx Fee $6,000
-PPO Discount $3,000 (Tx fee $6,000) - ($3,000 Allowable)
-Est Ins (LTM) $2,100
-Insurance will cover up to 70% of treatment allowable
($3,000) X (.70)= $2,100
-Pt resp $900 (Allowable $3,000) -(LTM $2,100)
500
Where discounts are applied in Greyfinch
What is under the Payer Section
500
What about COB's
Many plans and rules may apply to coordination of benefits. Detailed documentation is available for review.