When the Smart Fee function is used, a specific insurance reimbursement dollar amount may be entered per procedure which will update the insurance plan’s Smart Fee schedule. The Smart Fee payment amount is entered in the Smart Fee column. The amount in that field will update the estimated insurance amount for that specific insurance plan only.
In a non-PPO dental office, the Smart Fee function is a useful tool to calculate a more accurate estimated insurance portion within a particular insurance plan. When the office is not contracted with an insurance carrier as a preferred provider, the insurance carrier’s maximum allowable is not generally known. When an insurance reimbursement is received for the plan, the Smart Fees can be built for the insurance plan. The Smart Fee function will assist the office to determine the patient’s out-of-pocket portion more accurately, based on previous payment experience for that insurance plan.
Example, for a contracted PPO provider office:
· The maximum allowable fee for D1110 on a MetLife PPO plan is $100
· According to the plan details for group number 12345, MetLife will pay 100% of the Preventive category
· The calculated estimated patient amount would be $0 and the estimate insurance amount would be $100
For a non-contracted office:
· The Smart Fee schedule indicates a payment history of $85 for D1110
· The calculated estimated patient amount would indicate $15 and the estimated insurance amount would indicate$85
The Smart Fee calculation can occur even without the Smart Fee function turned on. That is, an office is able to create an individual Smart Fee schedule for an insurance plan.
· Click the word “Setup” and the “Insurance” and “Insurance Plans” options from the drop-down list
· Locate the desired insurance plan
· Click the SF tab
· Click the Edit Smart Fees button
· Enter the normally expected reimbursement amount for the procedure
· Click the Save button
Smart Fees are always available for usage – with or without the feature being turned on by Denticon. If the feature is not active, the smart fees can be updated manually by the office staff. If the feature is active, the Smart Fee schedule is built automatically upon the entering of insurance reimbursement amounts.
NOTE: When the Smart Fee function is active, the user must be vigilant when entering an amount in the Smart Fee column during a claim payment. The entered amount should be the amount that is always expected from the insurance carrier, regardless of the patient’s deductible or remaining allowable benefits. Care should be taken to fully understand the information on the carrier’s Explanation of Benefits (EOB) to determine if the reimbursement amount is the always expected amount for every patient on the specific insurance plan.
The Smart Fee amount will reflect the last entered amount for the procedure.
When the Smart Fee feature is active, the office can always leave the Smart Fee column blank which would not update the plan’s SF fee information. The user determines when to update the Smart Fees. The user must remain aware of the Smart Fee financial information regarding its relevance to all patients who utilize the same specific insurance plan.
In addition to being specific for a particular insurance plan, Smart Fees are specific to a particular office. In multiple location practices, the Smart Fee information recorded for one location will not automatically update another location. This restriction is programmed by design in order to allow for potential differences in insurance reimbursement, based on the zip code of the individual location. As a result, a Smart Fee schedule becomes specific for both the insurance plan and for the location.