Coverage Book Setup and Use in Eaglesoft - How Andre Does It!
FIRST, IF YOU'RE NOT SURE IF A COVERAGE BOOK (CB) IS ACCURATE, DELETE IT.
It's better to start a Coverage Book (CB) from scratch then to use it and be unsure if it’s accurate. You CAN delete CBs quickly and the Employer(s) connected to them will NOT be effected other than they will default to “None” for the Coverage Book.
SECOND Question: What is the difference between a Fee Schedule and a Coverage Books? Can you use both?
Answer: When you are in a PPO network you are given a Schedule of fee you are "allowed" to charge THEIR patients. The carrier is supposed to pay a percentage of those allowed charges. So, in my mind the carrier gave you a Fee (a payment made to a professional person) … Schedule (a written or printed list).
So for the Employers that are connected to that carrier I would attach a Fee Schedule and with that Employer (by group) I would connect percentages of those fees that the Insurance carrier covers as Service Types.
Now... In some cases, the categories (Service Types) DON'T follow the "norm" Example: A resin is Restorative UNLESS it is on a "back" tooth THEN it becomes a unicorn and doesn't follow the norm. THEN it is time to make an exception for THAT Employer/Group. THAT exception is the Coverage (the extent to which something deals with) Book (a written or printed work) or a list of exceptions to the percentage rule. SOOOOO an employer IN NETWORK.... CAN have BOTH attached. In most of my setups, I use Fee Schedule for 99% of calculation and Coverage Books to make up the gap to 100% (typically Posterior Resins)
Fee Schedules should ONLY be used with plans with “Allowed” fee.Fee Schedule are attached to Employers and NOT PatientsIn most offices, the ONLY things that need to be in a CB are the 4 odd ball code that don't follow a "rule" and those are the Post Resin Codes. IF you have the "correct" service types and you are In-Network there is NO reason to do more than that.
That being said: Test this theory. In a Test Patient post D4341/Scaling and Root Planing and D2740/Crown for the same Patient. Are they correct without a Coverage Book based purely on the Fee Schedule for the Employer Plan? Then you don’t need to add a Coverage Books. Now try a Posterior resin. Now the calculations are off. Time for a Coverage Books for that code and any others that is not calculating correctly. There are lots of variables but once address, IMO... you an get CBs down to the bare minimum FOR IN-NETWORK PLANS
FYI… They are Coverage Books not Coverage Booklets, Coverage Schedules or Coverage Tables in Eaglesoft.
THIRD: I’m not a big fan of Coverage Books as a PRIMARY Calculation method for in-network providers. If you are, you’ve been warned. Don’t comment that I’m “crazy” and that you “will always do CBs”. Fly, be free. Just not my cup of Tequila. I mean tea (LOL).Now that you have your Fee Schedule (FS) a neatly set up (see Fee Schedule Blog Entry) you can begin to create “Exceptions” to your FS Rules.
Example of a FS Rule:Example:Composite Filling $60PPO Allowance: $50In the Walkout, you post $60 > Eaglesoft will AUTOMATICALLY write off $10 > The Fee will show as $50. Based on the % in the Employer set-up (say 80%) the estimation will show as $40. Patient responsibility will be $10. The Day Sheet will show production of $50 in Production. NOTHING will show in the Adjustment column. In the Managed Care Utilization Report, $10 write off will show attributed to that insurance carrier.
So here is a scenario: Patient presents for the same Walkout but the filling is a Posterior Composite and the carrier downgrades. The same walk-out happens and Eaglesoft will make the same calculation. But this time it’s incorrect because, based on the tooth being Posterior, coverage doesn’t follow the “percentage of Fee Schedule” rule it follows a specific rule based on the tooth and not the procedure. The Carrier allows for 80% of a downgraded Amalgam Fee.
As an in-network Provider: in this example, you need an exception to the Fee Schedule rule - A Coverage Book.
To create a new CB, I create CBs based on the “Allowance Schedule” of that Insurance Company, so I name them based on that. Example: “Delta PPO Allowance Filings Only” or “Delta Premier Allowance Filings and Post Crowns”. That way if an employer moves to a new ins co, you can just change the Coverage Book. It won't be good anymore.
I recommend that you ONLY enter Service Codes into a Coverage Book that do NOT calculate properly using only the Fee Schedule and Service Type percentages.
As an in-network provider, I recommend
NOT using the Use Co-pay or Use Write Off options.
Entering the Carrier’s MAF in the UCR column
Entering Ignore in the Coverage Column
No other information needed to be added since the “Ignore” in the Coverage column send calculations back to the Employer screen and percentages and deductible application is considered there.
The "proper" Employer setup when you are In-Network with a Insurance Company is
Fee Schedule Matches the Insurance Company
Coverage Book is specific to the Employer
(unless a "generic" Coverage book can be used for a PPO planAdjustment type (while not needed) should match Insurance Company
As an Non-Participating Provider, Coverage Books take on a wholly different meaning. They act as a way of clarifying what an Employer Plan might cover because a Percentage of a Service might not apply outside the “network”. As a Non-Par practice, I always ask where the practice philosophy fall within 4 categories:
As a “Don’t Care” practice, insurance estimations are turned off so this isn’t a issue
As a “Kind of Care” practice, Insurance estimations are generic so there is no need for Coverage Books.
As a “Might Care” practice, insurance estimations are closer but Coverage Books are still not needed.
As a “We Care” practice, Coverage Books are essential and are entered Employer by Employer, Service Code by Service Code in the following setup:
Traditional No-Par who pay a specific percentage of their own Fee Schedule,
Do NOT use Use Co-pay or the Use Write Off.
In the UCR Column enter the MAF considered for calculations.
In the Coverage column enter Ignore. By using “Ignore”, the calculation is done using the Information in the Employer Screen
In the Covered column enter the percentage of the MAF considered for Calculation of Estimate.
In the Ded. Applies Column enter Yes or No.
Using “Dollar Amount” in the Covered column will cause the Deductible to be ignored no matter what.
Question: How do I delete a Coverage Book that is no longer accurate or no longer being used?
Answer: Simple: List>Coverage Books>Delete
This information was updated 9/25/2022
DISCLAIMER:
This is a resource guide and all decisions on each dental office setup should remain the sole decision of the dentist/owner of the practice. Eaglesoft is a registered trademark of Patterson Dental Company. All other software or products mentioned are the property of their respective owners. Although Andre Shirdan was an employee of Patterson Dental, he is not associated with Eaglesoft or Patterson Dental Company or endorsed by Patterson or any other Company Mentioned in this blog
