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Enters insurance payments

How to call a dental insurance company and gather EOB information (used when we never received a claim)

Many dental insurance companies are paying dentists through electronic funds transfer these days. This saves the insurance company money because they no longer print checks and mail them – and they often also no longer print an EOB (explanation of benefits) either. So, if the dentist wants to get a copy of the EOB, we need to contact the insurance company to get it.

In many cases, you can get the EOB from the dental insurance plan’s website. However, sometimes the claims are not available – just like any website, there can be technical difficulties. So, your foolproof way to stay on top of the collections and billing for your patients is to call the insurance company to get the information you need.

When you’re going to call an insurance company, you want to make sure you’re asking about every patient you can during the call. So, before you pick up the phone, grab your over 30, over 60 and over 90 days insurance aging reports. These print in alphabetical order by insurance company – so all the patients are grouped by insurance company. If you’re planning to call Aetna – look at each list to see the patient names you’re going to ask about. Sometimes you’ll see the same patient on multiple lists – that just means they were in multiple times and have claims that have been outstanding for different lengths of time.

Instructions:
1. Call the plan.
2. In EagleSoft, you can find the insurance company phone number in the patient’s account tab. Under the patient’s name click on the Insurance info tab – this shows the insurance company name, address and phone number. Use this number to call insurance.
3. You will start out in an automated system. Expect to press the keys on your phone to enter the dentist’s tax ID, your patient’s insurance ID number and maybe the patient’s birthdate. Many automated systems work with verbal commands, so you can speak these numbers instead. As soon as you can, ask for a “Representative” – the automated systems are programmed to understand that word and direct you to a real human.
4. For your patient, you will provide:
a. Member ID or SSN
b. Patient name
c. Date of service
5. Here’s what you need to ask:
a. How much was paid & on what date? Please fax us the EOB.
b. For each code, what is the allowed amount and how much was paid? Here’s a table you can use to see things more clearly:
Code              Allowed               Paid
1110                $55                       $55

The reason you need to ask about the allowed amount instead of finding out only what was paid is because the person entering the insurance payment, also needs to make sure the correct insurance withhold is entered as well.

How to enter an insurance payment & the insurance withhold

If you have a printed EOB reflecting an insurance payment, then you have 2 responsibilities: first, to enter the insurance payment and second, to make sure the correct fee is entered in your patient’s account ledger. Sometimes this is simple, other times it can be very confusing. Follow these instructions to enter accurate numbers every time.

In Dentrix

1. Open the claim in the Ledger

2. Click on Enter Payment.  There will be two options:

a. Itemize by procedure – if you itemize, you enter amounts received for the particular procedure and if you want to enter into the Payment Table

b. Total Payment Only or Enter Additional Payment

3. Once the Total Insurance Payment window opens, enter in Check # andor Bank/Branch #.

4. Under the Provider Amounts section, double click on the provider to open the Provider Payment window.  If the provider not listed, click Add.  The Provider Payment window will open. Be sure to pay the provider with the positive amount due.

5. Enter in Amount Paid

6. Click OK

7. Enter in any additional information for the payment, if needed.

8. Click OK/Post

To enter an out of network / fee for service insurance payment in Dentrix:

To enter an in-network insurance payment in Dentrix:

To enter an in-network insurance payment in Dentrix when your PPO Fees are already set up:

To enter an insurance payment in Dentrix between two providers – and see the plus/minus that can be created:

In EagleSoft

Go to the account screen for your patient. Click the insurance payment tab at the bottom of the screen. This brings up a list of all outstanding/open claims.

Click on the open claim that matches the date of service on your EOB. In the far left bottom screen enter the total amount of the insurance payment for the entire claim – all the codes added up together. The software will automatically allocate this total payment between the codes for that date of service. It bases this allocation on the fee schedule entered for that insurance plan. Sometimes it will be right, other times it will be wrong. This is your job to check and edit if needed.

Perfect match
The simplest cases are when the insurance payment matches the insurance estimate exactly. For example, if your patient was in for:
Dental cleaning D1110 $78 full fee and $55 insurance estimate
Periodic exam D0120 $34 full fee and $24 insurance estimate
And you receive an insurance check for $79. When you enter the $79 as the total payment, it will automatically allocate the $55 and $24 to the cleaning and exam. Click save – this brings up a window to show you the estimate vs. the payment and you click Ok to close this window.

Now, let me explain the different fees used with insurance. First of all, dental practices should submit their full fee to the insurance company – that means the dentist’s full fee will show up on the EOB, usually in the first fee column. Next, most dental software packages (set up properly) will enter the negotiated fee/ insurance allowed fee in the patient’s ledger. The purpose for sending the highest fee to the insurance is first, you never know when the insurance company might increase their negotiated fee and the dentist would be losing out if he sent this lower fee to the insurance plan and second, you want your patient (who also receives a copy of the EOB) to see your standard fee for each procedure and appreciate the true value of their dentistry. The purpose for the software automatically entering the negotiated fee into the patient’s account is to save time. When the insurance fee schedule is entered correctly, entering insurance payments moves along quickly and easily.

Edit the allocation
Now, let’s have you edit the allocation per code. In this example, let’s say you have a patient in for:
Dental cleaning D1110 $78 full fee, $55 allowed and $55 insurance estimate
Periodic exam D0120 $34 full fee, $24 allowed and $24 insurance estimate
And you receive an insurance check for $69. When you enter the $69 as the total payment, again, it will automatically allocate the $55 and then $14 to the cleaning and exam.

However, when you look at the EOB, you see that the insurance estimates are:
Dental cleaning D1110 $78 full fee, $55 allowed and $45 insurance payment
Periodic exam D0120 $34 full fee, $24 allowed and $24 insurance payment

  1. Go to the Insurance Payments tab
  2. Click on the View Selected Claim button if there are several listed.
  3. Enter the payment info – the date, payment type, check number and amount paid
  4. You can also click on the Note button to enter a note about this payment
  5. Click Save

Debit adjustments – when insurance overpays

Now, let’s have you create a debit adjustment. In this example, let’s say you have a patient in for:
Dental cleaning D1110 $78 full fee, $55 allowed and $55 insurance estimate
Periodic exam D0120 $34 full fee, $24 allowed and $24 insurance estimate
And you receive an insurance check for $80.

When you look at the EOB it shows:
Dental cleaning D1110 $78 full fee, $55 allowed and $55 insurance payment
Periodic exam D0120 $34 full fee, $25 allowed and $25 insurance payment
This means that insurance paid more than you estimated.

To make this account correct, you will need to enter a debit adjustment. First, enter the insurance payment in EagleSoft

  1. Go to the Insurance Payments tab
  2. Click on the View Selected Claim button if there are several listed.
  3. Enter the payment info – the date, payment type, check number and amount paid
  4. You can also click on the Note button to enter a note about this payment
  5. Now, since you have a credit – you will see at the bottom an amount in red along with the words “Total Unassigned” – this also shows a blue circle with an i and if you click on this blue circle it says “This amount is not assigned to services associated with this claim.”
  6. Just like before, click Save
  7. Now – you will see a Closing Primary Insurance box – if the patient has secondary, then you can submit it now. You also want to checkmark the box for Update benefits based on overpayment amount.
  8. Next, if you go ahead & close the primary then you will see another screen with two options for Close Claim Options – you want to choose “Do not adjust the account” and “Update benefits based on overpayment amount”

When you enter the $79 as the total payment, again, it will automatically allocate the $55 and then $24 to the cleaning and exam. Since $55+$24=$79, you have $1 left over. You will see this dollar listed as an unassigned credit – and it will show up in red on the right bottom of the screen underneath the allocation per code. Go ahead and click Save.

Now, on your account, you will see that your patient has $1.00 credit. You know they don’t deserve any money sent back to them – you have the EOB showing that the correct insurance payment means that we should have estimated $25 not $24 for the exam. So, to make this credit disappear, you will enter a debit adjustment.

To enter a debit adjustment, click on the adjustment tab at the bottom of the screen. Select debit adjustment at the far left. Enter the $1.00 in the Current box. Next, select “Insurance overpayment” or something similar that suggests “Insurance adjustment” in the adjustment type. Then click save in the bottom right corner of the screen. Now you should have a zero balance on this account.

Credit adjustments – when insurance underpays
Now, let’s have you create a credit adjustment. In this example, let’s say you have a patient in for:
Dental cleaning D1110 $78 full fee, $55 allowed and $55 insurance estimate
Periodic exam D0120 $34 full fee, $24 allowed and $24 insurance estimate
And you receive an insurance check for $70.

When you look at the EOB it shows:
Dental cleaning D1110 $78 full fee, $45 allowed and $45 insurance payment
Periodic exam D0120 $34 full fee, $25 allowed and $25 insurance payment
This means that insurance paid less than you estimated. In fact, it’s worse than just your insurance estimate was wrong – you have the wrong amount entered as the Allowed amount for that code.

To make this account correct, you will need to enter a credit adjustment.
When you enter the $70 as the total payment, again, it will automatically allocate the $55 and then $15 to the cleaning and exam. Since we charged the patient $55 for the cleaning – but we were only supposed to charge the patient $45, we it looks like the patient owes the extra $10. However, we are required to follow the allowed amount and not charge the patient more – so we have to give the patient a credit adjustment to bring their balance back down by $10.

First, go ahead and enter the $70 payment – you can use our first example to make the allocation amounts correct. Click save. Now, if this was the only visit for the patient, you will see that the patient owes $10. Next, to make this balance disappear, you will enter a debit adjustment.

To enter a debit adjustment, click on the adjustment tab at the bottom of the screen. Select credit adjustment at the far left. Enter the $10.00 in the Current box. Next, select “In network contract writeoff” or something similar that suggests “Insurance adjustment” in the adjustment type. Then click save in the bottom right corner of the screen. Now you should have a zero balance on this account.

Ups and downs
The challenge of entering insurance payments is when you have each of these situations on a code for the same date of service. If your patient comes in for a filling – and the insurance applies a $50 deductible, then you have to make sure you make the correct entries so that the patient’s balance is $50. If your patient comes in for several fillings and the insurance has a lower allowed amount on one code but a higher allowed amount on another code – you will have to keep track of how much you need to adjust up or down for each code – and then do the math so you only have one adjustment for that date of service.

When there are several codes for one date of service and the payments don’t match the estimates, I recommend using your calculator and a pen to track each code and write the adjustment on the EOB itself. You need the calculator to compare what was entered in the patient’s account vs. what the allowed amount shows on the EOB – and then write the difference beside that code. Using our examples above, if we ‘overcharged’ the patient $10 – because we thought the allowable was $55, when in fact it was $45 – then I would write “-$10” beside that code. If on the exam, the ‘undercharged’ the patient $1 – because we thought the allowable was $24, when in fact it was $25 – then I would write “+$1” beside that code. Then, I add these 2 adjustments together: -$10 + $1 = $9. I would enter a $9 credit adjustment for this patient.

To get signed off on this section, you must enter EOBs for 3 weeks with no errors. When you finish entering your EOBs for the day, place them on your office manager’s desk and she will check your work. Create a signature page with the dates you work for the next three weeks and hand that signature page in to your office manager paper clipped to the top of the EOBs each day.

Congratulations!

Entering insurance payments and creating accurate adjustments is a significant skill in a dental practice. You now have the ability to manage patient accounts, follow up on dental insurance and improve the cash flow of your practice.