Most practice management software programs should be able to determine patient portions (co-pay) based on that patient’s particular dental plan that you have entered into the computer. (We can use the words co-pay, patient portion, and patient share interchangeably.)
But let’s say you need to figure out the patient portion on your own.
Do NOT fear math. Do NOT fear math. Do NOT fear math.
Do not be the person who says, “I HATE MATH!” We aren’t asking you to do advanced calculus. We are asking you to do some VERY easy math in YOUR HEAD!
Let’s begin with a simple concept. Remember–we are doing this in your head. If you cannot estimate the math in your head to get the answer, then you will NEVER know if the numbers you are punching into a calculator are correct.
First of all, it is helpful to understand what 10% is of something. I estimate co-pays all day long starting with what 10% would be first. If you know 10% of something, then you can easily determine 20% of something (just double the 10% answer) or 30% of something (just triple the 10% answer) and so on.
For example, 10% of 130 is 13. That’s easy. So knowing that 10% of 130 is 13, to get 20% all we have to do is double the 10% answer to get 26. To determine 30% of 130, all we have to do is triple the 10% answer of 13 to get 39. Does that make sense? If not, please review this again until it does.
There are a few key pieces of information that you need to understand about a patient’s dental plan before you can figure out the math.
If the practice is in network, the agreed upon fee schedule must be used.
Procedure Benefit Category Payment Percentage
Categorize the treatment based on which category it belongs in-Preventive, Basic, and Major.
Has the deductible been met?
Benefit Maximum and Remaining Maximum
How much is a patient given a year and how much has been used?
Some procedures are not covered if the patient is too young or too old.
Missing Tooth Clause
Some benefits may not be paid out to replace a tooth if it was extracted under a different plan.
Some plans have time limits on covering a duplicate procedure on the same tooth.
Some insurance companies will reduce payment for a procedure based on material used.
The length of time after purchasing a dental benefits plan that a patient must wait before coverage for certain procedures goes into effect.
Kevin needs a filling!
According to Kevin’s specific dental plan, we can pull the following information.
The filling fee is $170. The plan is out of network and the fee is within the UCR, so we can consider the entire $170.
Basic is covered at 80% (Which means the patient owes 20% or .20–same thing)
$50 Deductible that is not met
$1000 Max and $800 Remaining (That means the patient has previously used $200 and we are not in danger of going over his max with this procedure.)
No Age Requirement per his plan. Missing Tooth Clause and Replacement Clause do not apply in this case. This procedure is not downgraded per his plan.
It is VERY EASY to determine the patient's portion in 3 SIMPLE STEPS.
Procedure fee minus unmet remaining deductible.
170 (procedure fee)
-50 (unmet remaining deductible)
Take that answer and multiply it by the patient responsibility percentage. Multiply it by the patient responsibility percentage because we are figuring out the patient portion.
120 (answer from previous)
x.20 (patient responsibility percentage)
Now, add that unmet remaining deductible back in.
24 (answer from previous)
+50 (unmet remaining deductible)
So in this example, the patient portion is $74.
If Kevin had already met his deductible, then the answer would be $34. 170-0=170. 170x.2=34. 34+0= 34
Does that make sense?
Joe needs a crown!
According to Joe’s specific dental plan, we can pull the following information.
The original crown fee is $1300. The plan is an in network plan which reduces the crown fee to $1000.
Major is covered at 50%.
$100 Deductible has already been met.
$1000 Max and $300 Remaining.
He is age eligible to receive this procedure. The Missing Tooth Clause does not apply. He previously had a crown on this tooth last year and the replacement clause is every 5 years.
This procedure is not downgraded per his plan.
There are no waiting periods on this plan.
In this example, Joe’s crown would not be covered at all, even though he has some remaining max because it has only been a year since the last time this crown was done. Per the replacement clause, the insurance company will not cover another crown unless it has been 5 years.