Best Practices for Handling Out-of-Network Insurance

Out-of-Network insurance

Insurance. It can be allusive with its acronyms and mysterious fees. It’s frustrating for office staff and patients alike, but read on to find out the best practices for setting up out-of-network insurance plans in Open Dental to keep the frustrations at bay and provide your patients the best possible estimates.

Using the Category Percentage Plan Type

When you’re dealing with an out-of-network insurance carrier, you’ll want to use the Category Percentage Plan Type when you’re setting up the Insurance Plan. This will ensure that Open Dental does not calculate write-offs as part of the insurance estimate.

When setting up the plan, make sure the Fee Schedule is set to “None”, otherwise you’ll end up charging patients the fees set in that fee schedule instead of your office fees.

Tracking Insurance Fees Using Blue Book

While insurance may cover 100% of a prophy, rarely do they cover your full office fee. When you’re in-network, it’s easy, because insurance gives you their contracted rates, but with out-of-network plans, it’s not so simple. They’re still paying a lower fee, but that fee can be a mystery since you’re not contracted with the carrier and they don’t provide a fee schedule.

With the Blue Book feature, you can easily track the insurance-allowed fees as you receive claims back, so future insurance estimates are more accurate. Enable Blue Blook in Setup, Family/Insurance, Insurance Blue Book.

Blue Book will use fees entered in from claim payments not only on the same insurance plan, but also from the same carrier, Group Number, or Carrier Group to help determine insurance estimates. Set your Insurance Blue Book Rules Hierarchy to determine which fee is used, if available. If there have been no fees entered on claims matching your Blue Book Rules, you can choose to use a UCR fee percentage (e.g., 80%) instead, so estimates are based on a lower portion of your office fee.

When receiving claims, enter the insurance fee in the Allowed column. Open Dental will track these fees as you receive more claims. (No need to create a fee schedule!)

If you ever want to know what rule or fee is being used to calculate an insurance estimate, you can look in the Blue Book Log found in the Claim Procedure details of a procedure.

No Assignment of Benefits

For those out-of-network insurance plans that your office collects payment in full and insurance reimbursement does come back to the office, but instead, the payment goes directly to the patient, follow these steps to make the process as seamless as possible.

Remove Assignment of Benefits from the Insurance Plan: On the Insurance Plan, in the Subscriber Information area, uncheck Assignment of Benefits (pay provider). This will indicate to the carrier when the claim goes out that any payment should go directly to the patient, rather than the practice

Enable Auto receive claims with no assignment of benefits in Preferences: Since payment for these claims is not going to be received by your office, they do not need to remain open. Enable this preference to immediately mark these claims as received with $0 payment once they are marked as sent.

If you have any questions, our friendly and knowledgeable Support Team is here to help.

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