Methods of Estimating Insurance

At check out, the software bases the estimate of insurance on the following search procedures:

The software looks in the blue book for code-specific coverage associated with the patient’s employer/insurance plan.
If there is no data on a code-specific employer/plan, the software then looks for coverage associated with a range of codes for that employer/plan; for example, all codes from XXX to YYY are covered at 80 percent of the UCR.
If there is no data on employer/plan code ranges, the software looks for code-specific coverage by the insurance company.
If there is no code-specific coverage for the insurance company, the software looks for coverage for a range of codes for that insurance company.
If there is no coverage for a range of codes for an insurance company, the software looks for an office-wide code-specific schedule of fees.
If there is no office-wide, code-specific fee schedule, the software looks for an office-wide fee schedule for a range of codes.
If there is no office-wide fee schedule, the software looks for ADA code-specific default insurance.

Example: A dentist treats three patients, patient A, patient B, and patient C. All three patients have the same treatment done, and the fee is $200.

Patient A has no insurance. Patient A pays $200. The software produces this figure from the office-wide default fees.

Patient B has insurance through his employer, Ben and Jerry’s. Ben and Jerry’s dental insurance is provided by Aetna. This plan states that Aetna pays 80 percent of the usual, customary, and reasonable charges for this procedure. The patient pays the difference, including any amount in excess of the UCR. Aetna has determined that the UCR in this instance is $180. Eighty percent of $180 is $144. Therefore, the patient pays $56, the difference between the $200 fee and what the insurance company pays.

The software produces this estimate from the code-specific amount for the procedure, as well as whether the patient is responsible for the amount in excess of the UCR.

Patient C has insurance through his employer, Fred and Company. The employer has the Regal Plan through Metropolitan Insurance. This plan states that the insurer will pay 80 percent of the UCR, and the patient does not have to pay anything in excess of the UCR. Metropolitan Insurance, like Aetna, has determined that $180 is the UCR. Therefore, the insurer pays $144, and the patient pays $36, the difference between what the insurer pays and the UCR. The dentist writes off $20, the difference between the combined amounts paid by the insurer and the patient and the standard fee.

The software produces this estimate from the code-specific amount for the procedure, as well as whether the patient is responsible for the amount in excess of the UCR.