How Andre Fools Eaglesoft when One Provider is In-Network and is One Out-of-Network
There are many practices where one Provider is In-Network and one Provider is Out-of-Network, this is fine until they BOTH see the same Patient. I have shown a similar technique when in-house specialists have their own fees. Typically, this happens with “Hygiene checks”.
When there is no cross over, the easy way to set up Eaglesoft is to have two identical Employers and one is attached to a Fee Schedules and/or Coverage Books and one is NOT attached to a Fee Schedule but uses a Coverage Book to calculate the Out-of-Network allowances. Addressed in the Eaglesoft Field Guide here:
You will need to create a NEW Employer. A copy of the Employer you already have. Make the new Employer identical in every way except for two things:
1) Make the name the same with the phrase “Non-Par” after the name. This lets you know that this plan will NOT adjust fee.
2) Do NOT attach a Fee Schedule to this duplicate employer. A Coverage Book may be a good idea if “true” estimation is being done for Out-of-Network transaction.
Out-of-Network Setup
So, let’s say Mr. Smith wants to see “Dr. In-Network” then you use “Conseco Construction”. If Mr. Smith wants to see “Dr. Out-of-Network” then that patient would be connected to the Employer “Conseco Construction Non Par”.
When the Patients flip-flops between both and In-Network and an Out-of-Network Provider, the problem becomes: you cannot “just swap” Employers on a Patients.
Here is my work-around:
1) Create Admin Codes for the Out-of-Network Services typically provided (Evaluations, Imaging and the Prophys).
2) Create Exploding Codes for Scheduling and/or posting with these codes.
Here are the steps:
Create an Admin Service Code for D0120. I typical format my Out-of-Network Service Code with a “O” in place of the “D” in this way:
This/these codes will NOT be part of the existing Fee Schedule attached to the Employer. When walked out, it will reflect the Standard Fee for the practice. If you want to go to the next step, you can create a Coverage Book to estimate based on the Out-of-Network allowances. Here is an Example of a walkout using this set up.
You can see with the “O0120” (first line) uses the Out-of-Network Provider’s Standard Fee of $56, there is no adjustment (because there is no Fee Schedule attached to this code; the Fee shows as $56. The estimated insurance is $28 because that is 100% of the Allowed Fee (pulled from the Coverage Book); The Patient coinsurance is $28. The same calculation happens in each line.
Here is the same walkout for an In-Network Provider using (first line) Service Code “D0120” and the calculation shows: Standard Fee is $56, there is a Contractual Adjustments (“write off”) of $28 because there is a Fee Schedule attached to this code; the Fee show as $28. The estimated insurance is $28 because that is 100% of the Allowed Fee (pulled from the Preventive Service Type); The Patient coinsurance is $0. The same calculation happens in each line.
I would also create Exploding Codes for these routine visits. Here is an Example of an Out-of-Network Exploding Code for an Adult Recare visit.
Here is an Example of an In-Network Exploding Code for an Adult Recare visit.
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
