#23 – Instructions to follow up on PTEs (Pre-treatment estimates)

Instructions to follow up on PTEs (Pre-treatment estimates)

  1. Anyone in the practice can submit a PTE at anytime. When these PTEs come back to us in the mail, they are given to _____.
  2. _____ enters the PTE into the patient’s treatment plan – she goes to the ledger, treatment plan presenter and then double click on each procedure & enters the dental insurance amount.
  3. Then place the PTE in the PTE file located in __________________.    ______ will add these patients to the weekly unscheduled list for follow up.
  4. ___________ will check the schedule to see if this patient is already scheduled for this treatment. If the patient is already scheduled, then _________ simply confirms our insurance estimate and existing financial arrangement.
  5. If the patient is not scheduled, __________ will send our Quick letter named GP EOB Letter #1 to the patient and document the date sent in the PTE log spreadsheet. To create this quick letter, click GP EOB letter #1 and then click Build/View to bring this letter up in Word. Edit the letter with the missing information (total amount insurance says they will pay and the total amount of their treatment plan). Type in your name above Financial Coordinator and sign/mail the letter.
  6. Scan the original PTE into the patient’s chart.
  7. Make a note in your planner for 5 days after you mail the letter to call the patient. It’s best to call in the evening in order to actually talk with the patient about their treatment and work out financial arrangements. Do not leave a message.
  8. Record the date & response of your call in the unscheduled spreadsheet.
  9. Try 3 times to call the patient, leaving a message on the last try – document all attempts in the PTE log spreadsheet. If the patient has an email address, you can send them an email as well. All of this contact should occur within 10 days total.
  10. If no response after your calls & your final voicemail, then send Quick letter GP EOB Letter #2. Again, click Build/view and edit the provider’s name that recommended the treatment.
  11. If you schedule the patient, mark them as scheduled on the spreadsheet.
  12. If you do not ever get to talk with the patient, then print the treatment plan and document your voicemails, letters and emails and give the chart to ____ to take to the next  doctors meeting. Our doctors will call patients who have not responded to our admin team contacts.

Thoughts on handling a patient that says “I want to know exactly what my insurance will pay before I schedule this treatment.”

  1. Look at the total treatment plan and total fee
  2. Estimate the insurance coverage – and determine how confident you are of this estimate (check the payment table to see if we have received payment on this code in the past)
  3. Figure out the patient’s portion and ask them how they would like to take care of that. Most of the time when patients are asking for a PTE to be sent, the treatment is total fee of about $2000. Since most insurance companies have a max of $1000, that will leave their portion at $1000. Patients will use waiting for a PTE from their insurance as an excuse not to schedule or to simply delay their decision on whether they want to have the dental treatment done bad enough to pay their portion! Your goal is to force the conversation & help them to realize what their portion will probably be and to help them to decide how they might cover that cost.Sample conversation (Let’s say that _____ left the office without scheduling her root canal, core and crown after her emergency visit with Dr. _____. The treatment coordinator is calling her from the unscheduled treatment list.)Treatment Coordinator         Hi ____, this is ____ with ___________. I wanted to follow up on the treatment that Dr. _____ recommended. I see that Dr. _____ recommended that you have a root canal, core build up and crown on that tooth that’s been causing you some pain. Did you have any questions about this treatment?

    Patient             No. But I do need to know what my insurance will cover.

    Secretary         Great, I’d be happy to help you with that. It looks like the total fee for all your treatment is $1500. My estimate for your insurance is that they will pay $750. That would leave your portion at $750. How would you like to take care of that?

    Patient             Well, I need to know exactly what my insurance will pay before I can figure out how I’m going to pay you.

    Secretary         No problem. The best way to do that would be to send a pre-treatment estimate to your insurance company. I can send this to your insurance company for you. It will show each procedure Dr. _____ recommends listed by dental code and after about 4-6 weeks, your insurance company will send us what they plan to pay for your treatment. This is our best way to confirm what your insurance intends to pay, however, you do need to understand that your insurance will not guarantee this amount – since no one actually signs this pre-treatment estimate from the insurance company, they still consider this an estimate. In our experience, insurance companies almost always pay according to pre-treatment estimates, but this is not a guarantee. Would you like me to send this for you?

    Patient             Yes.

    Secretary         Okay. So, I will send that out for you today. Now, have you been thinking about when you would like to get this treatment done?

    Patient             Not really, sometime next month would be fine.

    Secretary         You know, one thing you might like to do is to get a discount for paying in full on your portion. If you pay me the $750 of your portion by check you can receive a 5% discount and if you pay it with a credit card, you can receive a 3% discount. Then, what we can do, is to simply confirm our arrangement when we get your pre-treatment estimate back. How does that sound to you? (Be sure to check with your insurance company for approval on giving discounts on patient portion only)

    Patient             Well, I don’t know.

    Secretary         That’s okay. I just want you to know about our discounts so you can take advantage of them if that works out for you. We have several ways to work out payment arrangements, if you’re thinking of making a monthly payment. Does that sound like what you were thinking?

    Patient             Yes, I would rather just pay like $100/month.

    Secretary         You know, I could get close to that with our 6 month same as cash option. The way that works is that you would apply for our All Care financing program and once you are approved, you get 6 months to pay off your portion with no interest. Now, if you go beyond 6 months, you will pay interest. For the $750 that’s your portion, that would mean payments of $125/month – how does that sound to you?

    Patient             Sounds fine, let’s do that.

    Secretary         Great – let me just ask you a few questions and I’ll process this online, should only take about 10 minutes & we can get this done right now. Then I can schedule your root canal – sound good?

    — So, you have worked out the financial arrangements and you still send the PTE to confirm our insurance estimate. If you want, you can schedule the first visit in about 3 -4 weeks (we usually get our PTEs back in 3-4 weeks) and then the calls you make when the PTE comes back in are simply a confirmation of the financial arrangements you have already discussed.

    Sometimes, the patient or patient’s parents will want to schedule for the treatment before the PTE is received in our office.  That is fine – go ahead and schedule the appointment but make a note on the treatment sheet and in the system G notes that they wanted to schedule before the return of the PTE from the insurance company.

How to read a PTE and questions

For this section, we saved a handful of pre-treatment estimates in a binder and then created these type of questions for training;

  1. Look at Tom Jones returned PTE from Cigna.
    1. What is the % of coverage on the partial? _________
    2. Why is it only going to pay $246.00? ________
    3. What does note MC mean? _____________
    4. What amount will Tom be responsible for? __________
  1. Look at Tom Jones returned PTE from Klais & Co.
    1. Why is the amount payable by the insurance company different for the same filling code? __________
    2. What amount will Tom be responsible for? ___________
  1. Look at Tom Jones returned PTE UHC Dental.
    1. Does Tom  have to do the treatment in the order listed on the PTE? _________
    2. What does the EOB code J24 mean? _________
    3. Are you allowed to refigure what Tom will be responsible for based on a change of treatment? __________________
  1. Managed Care PTE’s. Remember that we have contracted with ____________________. You must be very careful when reading one of their PTE’s and take into consideration the allowed amounts as well as the payable amounts.  Look at Tom Jones PTE from ___________ as an example.
    1. What amount is the discount? _____________
    2. What amount will parents be responsible for? ________________
  1. Situations:
    1. A patient needs either a filling or a crown on a tooth. The patient wants to see what the insurance will pay for either.  What do you do? __________________________________
    2. A patient wants to replace a missing tooth. The patient wants to see what the insurance will pay for either an implant, a bridge or a partial.  What do you do? ________________________________________

To get signed off on this section, you must be able to:

  • Understand how to read a Pre-treatment estimate
  • Know how to enter a PTE into the dental software so the insurance estimate matches the PTE
  • Set up a system to assign who will be responsible for PTEs when they come in – as well as who is responsible for entering them into the dental software, who will reach out and call the patients, and how this is followed up with the doctors.
  • ___________________________                            _____________

    Team Leader                                                               Date