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In this episode I will walk you through some tips on generating the most accurate insurance estimate in Dentrix when you are an out of network provider. It does get a little tricky when you don’t have a fee schedule to calculate from, however over time you can create some tables that will help.
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Transcribed by Riverside AI. Please ignore all grammar and punctuation mistakes.
Dayna (00:02.55)
Hey there, welcome back. So last week, I had a few people reach out to me after last week’s episode, because I talked all about if you are in network, what is the best setup or what are the setup options when you’re in network to provide your patients with the most accurate out of pocket expense for treatment plan or on the ledger.
And so the reason why we were talking about insurance, fee schedules versus allowed amount was because the ADA just released a guide for you for helping you kind of navigate the path of terminating network contracts. And so if you missed that episode, that was last week, you can dive into that if you are in network and you wanted to hear my options.
for the fee schedule method versus allowed amount method. Go back to last week, it was episode number 85, and you can re-watch, re-listen to that one. And then I also had in the show notes, the link to that guide. And so I had lots of people reach out to me and they’re like, well, Dayna, we’re fee for service. We’re not in network with anyone. So what are our options for us to get the most accurate insurance estimates for our patients’ treatment plans?
Well, it does get a little bit trickier. It’s a little bit more challenging when you are out of network because you don’t know what fee they’re going to allow. And so you don’t have that fee schedule. You don’t have that allowed amount in your coverage percentages to use. So you’re kind of guessing as to what fee they’re going to allow you to charge.
it’s called UCR, usual and customary, because they’re gonna look around in your geographical area where your dental practice is located, and then they’re going to allocate a fee for your services based on your geographical location. So it’s possible that your full fee for a crown is $1,900.
Dayna (02:19.798)
But then what the insurance company is going to say is the UCR for a crown in your area is only $1,500. So there’s a difference of $400 there, but the patient is gonna have to pay the difference. And so you just don’t know exactly what UCR fee, the insurance companies are going to be paying on. So it does get a little bit trickier when you are fee for service. Now, of course,
there’s still significant benefits to being fee for service. You know, it is less insurance set up because it is just an estimate. You can’t get as accurate an estimate, but the patient just owes the difference and they know that. So, you know, there’s significant benefits of being fee for service because the insurance companies don’t dictate your fees.
They don’t dictate what you’re allowed to charge your patients for your treatment. So you are not bound to those rules and regulations. And there’s benefits in the sense that you don’t have to abide by the insurance’s rules so much when it comes to fees and limitations and frequencies and things like that. And that can help to bridge that.
that relationship between the provider and the patient because the insurance company doesn’t meddle with your treatment as much. They don’t get in the way as much because you’re not bound to their frequency rules or their limitations or things like that. But there is a little bit more of a challenge in the sense that the insurance estimate is a little bit trickier to get. Now another thing with being out of network,
is a lot of times the patient is getting paid, especially with Delta Dental. Most of my practices that I work with that are out of network with Delta Dental, the insurance checks are going to the patient. And so then you’re collecting full fee anyway from the patient because if they’re getting the insurance check, you’re just gonna collect full fee and then the insurance check is going to the patient and they get to deposit it or
Dayna (04:45.386)
I don’t know, maybe they can sign it over to you. But if that’s the case, if you are out of network with Delta and the patient is getting paid, then make sure that you’re putting some kind of a pop-up, like you’re using a patient alert or some kind of an alert system where you know that the insurance check is going to the patient, so you collect full fee on the day of service regardless. You cannot…
extend out any kind of benefits to those patients because they’re going to get the insurance check and then if they get the insurance check as well, you know, then it’s going to be harder for you to collect money. And we always remember, if you’ve been listening to me about any kind of counts receivable, you know that your money is worth more today than it is even 30 days from now. So even if you’re waiting 30 days to send the patient a billing statement,
and your fee for service and you wait 30 days, you’ve now lost about 15% of the value of that money. So you wanna make sure that you are collecting in full on the day of service, that’s really, really important. Now, as soon as we come back, I’m going to give you some of my best tips for estimating when you are out of network, when you are a fee for service practice.
Dayna (06:19.934)
Okay, so let’s dive in to if you are out of network, then there’s a couple tips I’m going to give you. And because you’re gonna be posting full fee to the treatment plan and the ledger. And what I wanna tell you is in the insurance, when you go into the benefits and coverage, the coverage table is gonna probably be your first line of defense when it comes to estimating.
And so if you are checking on the benefits for the patient and it says, you get the facts back or you get the online benefit review and you want to look at the review, and if it says that they pay, say, 100% on preventative, 80% on basic, 40, 50% on major, so if they’re telling you that they’re estimating that, but you know that you’re out of network,
What you can do is you could change the coverage percentages in dentrics and just lower those percentages. So you could say, okay, if they say they’re gonna pay 100% on preventative, but I know they’re probably only gonna pay about 85%. So I could drop that percentage down. So if they say they’re gonna pay 80% on restorative, they’re probably only gonna pay about 60% on restorative. And then maybe if they say they’re gonna pay 50% on
major, I’m gonna drop that down to 40 or 35%. So you can estimate low. I would recommend that you estimate low rather than estimate the way they say because then you may end up having to collect from the patient. The patient would much rather receive a credit or receive a check from you for a refund or receive a credit on their credit card as a refund because you over collected.
than they would to receive a billing statement for the balance because you underestimated. So just think about that. I would much rather overestimate and owe the patient money than underestimate, and now we have to chase the patient for money. It will keep the relationship better because anytime you have to chase money, now you’ve kind of broken that trust with the patient a little bit, and maybe
Dayna (08:45.718)
They might not think that your estimates are going to be right on, but if they get a check in the mail or they get money back, they’re like, great, my insurance paid more than we thought. So they’re going to be happy. They’re going to be super happy with you. Now the other thing that you can start doing if when you’re out of network is the payment table can be your best friend. Okay. The payment table overrides the coverage table.
And so as you are entering in your insurance payments, you can start populating or start updating the payment table as you’re entering in those insurance payments. It can be really fantastic for giving patients estimates. You can also manually populate the payment table. So if you know that this insurance company downgrades on posterior composites, you can go in and put in
you know, once you calculate the fee, so once you calculate the payment, which is going to be a percentage based on the amalgam fee, if you know, maybe you’ve gotten an EOB back from an insurance company, you wanna go in and enter in the downgrades, maybe on a couple other plans that you know are the same, you could do that, go in and enter in the composite codes with the calculation based on the amalgam fee. That also works really well.
with the fee schedule method. I didn’t mention that last week, but if you’re using the fee schedule method with Dentrix, because you’re in network, the posterior composite downgrades works really well in the payment table when you are in network and using fee schedules as well. Now, you can also put in procedures that don’t get covered at all. So let’s say you got a fax back or you’re checking insurance benefits for a patient and…
the benefit table says that they pay zero on occlusal guards. So you could put in the D9945, I think is what it is, with a zero in the payment table. Because that zero then will override whatever coverage table percentage you have in there. And so the payment table can really help you to get better estimates for your patients. Now, it’s probably going to take time.
Dayna (11:08.586)
You know, as you are entering in those EOBs, you can start populating the payment table. So it is going to take time, and it’s kind of an ongoing process to update the payment table. But it can sure help you to give your patients better estimates. And so take advantage of that payment table as much as possible when you are out of network. And then the other thing that you can do when you’re out of network, or if you’re in network for this matter,
for that matter, but there is a way that you can override the insurance estimate if you go to the treatment plan and on the treatment plan procedure code, if you open up the procedure code, there is a dental insurance override button that you could override the estimate. For example, if the patient has, you know, they’ve maxed the frequency, like maybe they just had a crown done a couple years ago and they want it replaced.
then you could override that with a zero because you know the insurance isn’t gonna cover it. Or maybe it’s aesthetics and you know it’s not gonna get covered. You could override the estimate with a zero. So those are some ways that you can make your fee for service insurance plans estimate better. So as you’re entering in the insurance payments, or maybe you’re outsourcing your insurance.
management like your claims management to a company we refer to bond dental billing so if you’re working with bond dental billing or maybe e-assist and they’re entering in your payments for you make sure that they understand how to update that payment table for you as well when they’re entering in those payments because that will really significantly improve the estimating process when you’re out of notes
All right, I hope that helps for all of you that are out of network and reached out to me with the DMs and said, hey, Dana, what about us that are out of network? I hope that this helped you to understand how to get the best insurance estimate. And also remember, I said this last week, but not, we just rerecorded our entire dental insurance 101 course that has all the details on how to make all of this work. So we…
Dayna (13:29.15)
share our screen and show you exactly what fields you’re going to put all this information. So if you’re interested in taking a deeper dive into insurance, then I would make sure that you take and purchase Teresa Duncan’s insurance course. So in this podcast, you heard that she is giving us a $75 discount on the course. So just use the Navoni 75 coupon code for that.
And then also our Dental Insurance 101 course, which is specifically geared towards dentrics and how to set it up properly. You can dive into our membership anytime. Just go to the website, Navoni website. There’s a green Join Today button in the upper right corner and you could be a member as fast as five minutes from now. So.
We look forward to seeing you next week, well, hearing you next week. And our special guest, Teresa Duncan, will be on the podcast, so I’m super excited about that. And I’m just always looking forward to watching your journey of becoming a Dentrix superuser. So if you found this podcast today helpful, if you found that you want to share it with your Facebook groups, with your study clubs,
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So until next time, I hope you have a great rest of your day and I look forward to watching your journey of becoming a Dentrix super user.
