What is a deductible?

[maryh320]

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Hi everyone,

I recently started working in a dental office doing some front office work and I ran into a couple questions.

I have no idea how deductibles work? does anyone know what is it meant by "Meeting a deductible". Let's say the annual deductible is $25, do patients have to pay their copayment AND the $25 deductible?


Sorry I am really confused with the concept of deductible, I would really appreciate if anyone can explain it to me before I make any billing mistakes. Thanks so much!

Mary

 

[ItsGavinC]

Originally posted by maryh320
Let's say the annual deductible is $25, do patients have to pay their copayment AND the $25 deductible?

Mary, I am certainly not the wizard at this, but given this specific situation my thoughts are that:

1) the patient pays the copay for SEEING the professional.

2) Insurance picks up the procedure fees AFTER the patient meets their deductable ($25) out of their own pocket.

 

[ShawnOne]

The entire deductible must paid before insurance kicks in. After the deductible is met, the co-pay is what the patient is responsible for on each specific procedure.

Usually the deductibe amount is subtracted from the check/funds the insurance company will send.

Typically,
After the deductible is met...
Diagnostic and preventative procedures have zero copay. Restoritive services (fillings) have about 25% co-pay, and major work (crowns bridges) have 50% copay.

These are rough numbers of course and will vary depending on insurance plan.

 

[maryh320]

THanks Gavin and Shawn for your input,

From my understanding, let's say a patient is getting a filling, cost about $300, for example. Normally, diagnostic/preventive services do not require a deductible, however, treatments such as restorative or others do need a deductible.

So patient has to pay $25 (for example) for his/her deductible, and pay a typical of 20-30% of their co-pay right?

As Shawn mentioned, insurance can go ahead and pay the 70-80% of the fee. Is the deductible paid to the dentists or to the insurnace company??Is the deductible paid to the dentists or to the insurnace company??

 

[ShawnOne]

From my understanding, let's say a patient is getting a filling, cost about $300, for example. Normally, diagnostic/preventive services do not require a deductible, however, treatments such as restorative or others do need a deductible.

No, deductible is not dependant on procedure, its will apply to all services.

Its the co-pay that varies.

Here is an example situation.

Patient has 50 dollar deductible, 0 copay on prevent/diag, 25% on restoritive, 50% on major. $1000 max per year

Actually, first things first, make sure you check thier eligability, and also check it EVERY time the patient returns. You'd be surprised how many people's insurance will discontued for whatever reason. Also check to see if they are over the limit. Never assume. (Take if from me!😡 )

So the patient come in and gets an exam, xrays, and a prophy. Lets say your fees are $200. The patient should pay $50 to cover the deducible (which needs to be paid every year) and insurance will pay the remaining 150. Now lets say they also need a class two filling. The office fee is, say $200, the insurane will pay 75%, so another 150. The office is supposed to collect the remaining 25% from the patient, which is the co-pay.

You'll get the hang of it. Is the office using a computer to send it electronically?

 

[maryh320]

Oh i see...so the deductible is only paid 1x a yr??

Wow, Shawnone, you are so knowledgeable about the billing part. I am having a hard time getting a hang of it, it's worse when our fee schedule keeps on changing.

We are printing the claim forms out and send it thru mail.
Do electronic claims get processed a lot faster?

Mary

 

[ShawnOne]

yeah, its faster, helps the cashflow situation for the office.

Many offices are now paperless. Most insurance companies will require x-rays for certain procedures. Offices can now send the x-rays digitally too. Really cool stuff..

Make sure you learn about getting "authorizations" too.

 

[larryt]

Crazy idea ....

Ask any dental office, not many of them really enjoys electronic filling. On average, 25-30% of electronic filling cases go whack even though they are filled by an experience person. Many of dentists that I have known (14 to be exact) do not like those electronic filling stuffs at all.

 

[Barry20]

Larry,

Thats probably because they had someone do it that didn't know what they were doing. Also, it is an insurance tactic to claim that they never received the claim that was submitted to them. This sometimes puts a false impression in the dentist's head that it's the computer's fault. I assume that the only reason the 14 dentists don't like it is because they end up with outstanding claims and have to do follow up in order to get paid, however this occurs with paper claims. Bottom line: as shawn pointed out, we are in the 21st century where computers are expediting everything so if you have an office where electronic claims are not being used, there's a problem. Hopefully in the next few years the minor problems with electronic filing will be resolved, but it's MUCH less of a hassle than stuffing envelopes.

 

[ShawnOne]

Businesses are scared of change (uncertainty). Thats true for ALL businesses, not only dentists. Thats why IT people have a hard time in most companies, because they have to convince stubborn managers that the applications really work.

Its also funny to see managers blame the "stupid computer" when they cant get something to work properly.

 

[larryt]

Originally posted by Barry20
Also, it is an insurance tactic to claim that they never received the claim that was submitted to them. This sometimes puts a false impression in the dentist's head that it's the computer's fault. .

This is exactly what I mean .... especially for Medicaid, Medicare and some private insurances. To my surprise, this electronic filling process is working well for the office with less than 15 patients per day, and not so well for offices with 40-45 cases per day. All of the dentists that I have known are around my age 27-35, all are computer literate.

 

[SpringHaze]

Electronic filing can't be any more of a hassle than filling out paper forms. My dad is in the office for about 2 hours after everyone else leaves, just filling out all the information on the paper forms (my mom and I can't get him to get a computer in the office). And yeah, alot of insurance hassles have nothing to do with the type of filing anyway. We've had all different kinds of problems, like the insurance company entering in the wrong date of work done, and even having no record of the form being submitted.
And for the record, there are some insurance companies that waive the deductible for preventive and diagnostic. Also, I'm not sure if you're still wondering, but the deductible goes to the insurance company, it's not like a stipend to the dentist or anything.

 

[maryh320]

Getting back on the deductible questions:

So the deductible end up in the insurance company. The way insurance make sures patient pays for his/her deductible is by subtracting that amount from payment to the dentists. It is therefore dentist's responsibility to collect the deductible up front before claim is submitted? correct??



As far as technology goes,
the dentist in my office just recently added a computer to her office after 29 yrs of practicing. She's pretty computer illiterate, barely knows how to save file and read emails.
So what are not totally paperless yet, it's nice to have a paper set of records just in case if the hard drive dies someday. We do back up our dental files up every month.
On top of that, we have day-sheets to record all the transactions, insurance payment log and ledgers. (all paper).

I think it's good for an office to have both electronic billing system and a paper record. What we do now is use Easy Dental to keep track of all patient info, and print out insurance claim form, so we do not have to fill anything out on paper, then mail it out.

 

[SpringHaze]

Oops, sorry, what I meant to say about the deductible is that it's not that it is money paid to the insurance company, but it's money that the insurance company won't pay for. Say a patient had a filling done for 200 and there's a 50 dollar deductible they hadn't fulfilled yet for the year and coverage for fillings is at 80%. So without the deductible the patient would only owe 40 dollars, but with a deductible, you subtract 50 from the total of 200, and only the amount left is covered for 80%. So in that case the patient would owe 50 dollars plus 20% of 150.
Does that make sense?

 

[maryh320]

Yes! I finally understand it now! My co-worker tried to explain to me over and over again at work and I really couldn't completely understand it. But I got it now!


Thanks Springhaze, Shawnone, Gavin and everyone else who contributed to this thread!

Mary