Tuesday, March 7, 2017

Why Don’t My Insurance Estimates Match the Estimates Dentrix Calculates?

One of the questions that often comes up in customer service phone calls is:

"Why don’t the estimates I calculate by hand match the estimates Dentrix calculates?"

In order to calculate the correct insurance portions, Dentrix uses formulas that reflect real insurance adjudication practices. Most importantly, these formulas use specific orders of operation to arrive at the insurance portion calculation. As a result, if you try to manually calculate these portions without using the same order of operations, you may arrive at a different amount.

For example, let’s say that your patient Bob will be charged $152 for a procedure that insurance usually covers at 80%. First, Dentrix will determine which formula to use.

  • If Bob does not have a deductible to be applied, the formula used is:
    (Insurance Portion) = (Charge Amount) X (Coverage %) or (Payment Table Amount). So the Insurance portion would be ($152 X .8) or $121.60.
  • If Bob has a $50 deductible to be applied, the formula used is:
    (Insurance Portion) = (Charge Amount - Deductible) X (Coverage %). So the insurance portion would be (($152 - $50) X .8) or $81.60.
  • If Bob has a $50 deductible to be applied and there’s a $96 payment table entry, the formula used is:
    Insurance Portion = [(Pay. Table Amount / Coverage %) - (Deductible)] X (Coverage %). So the insurance portion would be ([($96 / .8) - $50] X .8) or $56.

As you can see, even though the charge amounts are the same for each example, the insurance portion is different depending on which formula Dentrix uses to perform its calculations. If you don’t use the same formulas Dentrix uses or you don’t do the math in the same order as Dentrix, your results will be different.

Creating accurate insurance estimates is part of the new course called Estimate or Guesstimate? Getting Insurance Estimates Right in Dentrix, which will be offered at this year's Business of Dentistry Conference. Click the link to view conference details and to register.

No comments: