Incorrect insurance adjustments can kill practice profits

By James Anderson, DMD, DrBicuspid contributing writer

March 19, 2020 -- If preferred provider insurance adjustments seem high in your practice, it could be because your business staff is incorrectly posting the adjustments. That is a mistake that can severely affect your cash flow.

I received an inquiry from a dentist who couldn't understand why she wrote so many insurance refund checks to patients every month. It was later discovered that the business coordinator was posting the ledgers with an old insurance fee schedule, and, when the insurance paid, it showed an overpayment, resulting in incorrect credit balances.

James Anderson, DMD
James Anderson, DMD.

A credit balance occurs on an account when more money is collected either from the insured/guarantor or the insurance company than is estimated to be paid. If the patient hasn't paid anything toward the coinsurance or deductibles and there is a credit balance on the account after the insurance pays, the patient isn't owed any money. If an outdated fee schedule is used to make a treatment plan but the current fee schedule is billed to the insurance, there will be a credit balance to the patient. Before writing any refund, make sure to examine where the charges originated, if all are correct, and whether the current fee schedule was used.

Even though production adjustments will be higher, all insurance claims must be sent with the dentist's or practice's current standard fee schedule and not a preferred provider organization (PPO) schedule. Your usual fee schedule should represent the marketable fees for your geographical area and your determination based on the costs to do business. Insurance companies determine whether to raise their reimbursements to dentists based on the dentist's standard fee schedule and utilization codes statistics.

When the payment arrives, and the explanation of benefits (EOB) is attached or included, you will see a breakdown of the charges and the allowable amount and deductions. Any adjustments will be noted per contract with you. If the EOB seems wrong, don't hesitate to address it with a phone call or appeal. For the most part, the EOB is a correct guide to the proper recording of insurance payments. When recording the payment at the same time, update the coverage table.

Having a trained professional insurance coordinator on your team or outsourcing to a dependable dental billing organization will save thousands in incorrect adjustments. It is vital to proper collections of coinsurance (co-payments) that the coverage tables for each insurance group in the network be updated in the software system. When you have the correct numbers on the file, you can create a realistic financial estimate and expected insurance reimbursement on a document for the patient to discuss and accept.

Collecting every cent that is legally owed to you can be challenging when you don't have the knowledge to manage the accounts correctly. Make sure this isn't a problem in your practice and for your business.

James Anderson, DMD, is a practicing dentist in Syracuse, UT, and is the CEO and founder of eAssist Dental Solutions. He can be reached via email.

The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.


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