June 2, 2018 at 4:31 pm #1417
Our practice wants to offer an all inclusive mandibular package for one set fee to all patients who choose to have the service. The package would include however many needed extractions, any needed bone grafting at the time of extractions or at the time of implant placement, an immediate denture for healing after extractions, 2 implants for denture stabilization and a final implant supported removable denture. The number and type of services provided in the package would always total fees fee that would always be less than the total amount of what the PPO fees would add up to for all of the services that end up being provided. As you can see, because the number and type of extractions, and the varying bone grafting needs, and any other surgical needs would differ in almost every case, a set “discount” would not be possible. We’re thinking we might need to calculate the actual discount for each and every case. We were thinking we would treatment plan at the PPO fee schedule and determine the actual discount for each case against the flat package fee, and then whatever that discount % turns out to be for each individual case, use the discount feature on the treatment planner that would take apply the discount for each and every serve provied, and then bill out the discounted fees on the claim (instead of the U&C regular fees that we normally do). Would this be the correct approach? Again, the package fee will be the same flat rate fee in every case regardless of all of the needed services we actually provide.
I’m concerned that the insurance plan may not pay against what we bill on the claim. I’m thinking they may pay against the PPO fee file they have set up for us. Maybe you can help me understand how the insurance company reviews (or doesn’t review) a claim. sorry this is so long, but it seems complicated to me. LOL!
Thanks for any thoughts anyone may have on this subject. We want to give our patients a great offer and service, and we want to pass that discount on to the insurance plan (assuming that is what we should do). Thanks again.June 2, 2018 at 5:58 pm #1418
Okay, great scenario. I see this a lot in prosthodontist offices. They will treatment plan one procedure and call it Upper Arch and then detail in the note what all is included in the fee. Then as your treat your patient you can submit the procedures to the insurance company as you go. At the end you can adjust the balance to the fee you quoted the patient. See the screen shot attached.
For your specific question you will have to bill the insurance company for some of the procedures because you are a contracted provider. This issue you will face is that some of the procedures (grafting, other surgical procedures) will require a provider write off so you may want to get a form in writing from your patient that states you can withhold these procedures from sending to insurance.
Treatment plan is $12k – this is what is given to the patient and you create the financial arrangement off this amount. Make sure you save a copy of this treatment plan in the Document Center and sign it so it gets locked up. You can set the patient up on a Payment Agreement, have the patient pay in full or use an outside financing company.
Bill out the procedures as you treat the patient and send to insurance. Make the proper PPO adjustments as you go if you are sending UCR fees, if you are sending PPO fees then you don’t have to worry about this. The insurance company will look at each procedure code and match it up against your filed fees.
At the completion of the treatment adjust the account accordingly to reflect what you quoted the patient.
Under the Omnibus Rule the patient now has the freedom to not have procedures billed to their insurance company. This can help with these types of treatment plans. Let me know if you need a copy of this rule.
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