I need some thought process help

[sofamonkey]

So, I work in a dental clinic. We are a LOT of underserved community members. We take the state Medicaid insurance, which has and always will reimburse at extremely low rates. There are not a lot of providers that accept state insurance for adults, and the ones that do are super busy, hard to get into, and rushed.

That being said, they raised their rates a bit. I am trying to figure out if we should continue to raise our rates with their fee schedule, which is now higher than our fees. If we do that, the uninsured will also pay that rate. I’m trying to figure out if we are being fair to our clientele.

For reference, we charge $20 for a new patient exam, and all X-rays. For deep cleaning, we charge $45 per quadrant, so it’s $180 for the entire mouth.

It’s still a LOT less than a private practice office, but I really don’t want to price people out of care. I know there are a lot of very smart people on here, and if you could help me think this through, it would help me a great deal. My boss will take my lead, I just need to know which direction to push - keep current pricing, or raise things about $5-10. Thanks in advance for your time and help with this.

[icedcoffee]

I think it depends on your costs. Your rates should equal what it costs you to do the procedure. If you're covering your costs at the current rate then keep it the same!

[sofamonkey]

May 19, 2023 11:26:33 GMT -5 icedcoffee said:

I think it depends on your costs. Your rates should equal what it costs you to do the procedure. If you're covering your costs at the current rate then keep it the same!

We’re a school. We absolutely do not cover our costs, and would never without a substantial increase. We try to offset costs with our fees. Supplies have gone way up the past few years, which is why we’re even considering it. And even with that, I’m torn. Since we will never break even, I’m trying to weigh offset with community need, and I’m struggling hard here. I don’t want to price out people in need.

[TR]

I'm confused and maybe it's because I don't understand reimbursement rates correctly. Are you charging over the reimbursement rate so some is coming OOP from the patient? Would you be changing that delta by raising your rates?

[icedcoffee]

May 19, 2023 11:31:51 GMT -5 sofamonkey said:

May 19, 2023 11:26:33 GMT -5 icedcoffee said:

I think it depends on your costs. Your rates should equal what it costs you to do the procedure. If you're covering your costs at the current rate then keep it the same!

We’re a school. We absolutely do not cover our costs, and would never without a substantial increase. We try to offset costs with our fees. Supplies have gone way up the past few years, which is why we’re even considering it. And even with that, I’m torn. Since we will never break even, I’m trying to weigh offset with community need, and I’m struggling hard here. I don’t want to price out people in need.

Oh gotcha.  I'd increase it.  Maybe $5 this year and another $5 next year so it's phased in.  What's the percentage of uninsured vs medicaid?  Most probably have some form of medicaid, right?  So the majority will still be covered?  I mean, if medicaid is increasing it I would go with that because that's rare.

[waverly]

Does the exam include regular cleaning?

I guess I’m confused because you have a price for deep cleaning but what is the price for regular cleaning?

$20 is cheap for an exam so I definitely think it could be $30.

I would leave the deep cleaning the same since $180 is a lot more.

[thejen626]

Can you have a non advertised “uninsured rate”? Planned Parenthood does a sliding scale based on income.

[charlive]

A lot of places around here offer a 'cash price' for uninsured patients. So, basically, you get a discount if you're uninsured, but if you have ins, they'll bill the full amount. Is that not allowed?

[seeyalater52]

May 19, 2023 11:46:05 GMT -5 charlive said:

A lot of places around here offer a 'cash price' for uninsured patients. So, basically, you get a discount if you're uninsured, but if you have ins, they'll bill the full amount. Is that not allowed?

This is what I would suggest.

[goldengirlz]

May 19, 2023 11:46:05 GMT -5 charlive said:

A lot of places around here offer a 'cash price' for uninsured patients. So, basically, you get a discount if you're uninsured, but if you have ins, they'll bill the full amount. Is that not allowed?

From what I understand about medical billing, this is generally how it works in medicine. Few people actually pay the wholesale price. Insurers get a negotiated discount and uninsured patients can ask for one too.

I don’t know why you wouldn’t try to collect the full amount from Medicaid (and commercial payers for that matter) but, unless there’s a state law I’m not aware of, I don’t see why you have to charge uninsured patients the same prices, especially when the price for them would be lower.

ETA: Do you advertise your rates? Is that the concern?

[sofamonkey]

So, doing two fee schedules isn’t really ideal. If patients change insurance etc, plus h the volume of patients, it’s better to just have the one schedule. We see about 160-200 patients per week, and it’s just me and a part time person.

Our new patient fee is a company wide promo type thing, so that won’t change. The exam is just X-rays and exam. The cleanings range from $60-180 (light cleaning to the deeper, get numb per quad cleaning)

I hope I addressed all the questions, but I will look again. Sorry and thanks.

[sofamonkey]

May 19, 2023 11:42:48 GMT -5 icedcoffee said:

May 19, 2023 11:31:51 GMT -5 sofamonkey said:

We’re a school. We absolutely do not cover our costs, and would never without a substantial increase. We try to offset costs with our fees. Supplies have gone way up the past few years, which is why we’re even considering it. And even with that, I’m torn. Since we will never break even, I’m trying to weigh offset with community need, and I’m struggling hard here. I don’t want to price out people in need.

Oh gotcha.  I'd increase it.  Maybe $5 this year and another $5 next year so it's phased in.  What's the percentage of uninsured vs medicaid?  Most probably have some form of medicaid, right?  So the majority will still be covered?  I mean, if medicaid is increasing it I would go with that because that's rare.

I think we’re about 1/3 Medicaid, 1/3 private pay, 1/3 other insurance. We do try to encourage more uninsured to apply for Medicaid, since the application process is very simple in WA.

[sent]

May 19, 2023 12:22:33 GMT -5 goldengirlz said:

May 19, 2023 11:46:05 GMT -5 charlive said:

A lot of places around here offer a 'cash price' for uninsured patients. So, basically, you get a discount if you're uninsured, but if you have ins, they'll bill the full amount. Is that not allowed?

From what I understand about medical billing, this is generally how it works in medicine. Few people actually pay the wholesale price. Insurers get a negotiated discount and uninsured patients can ask for one too.

I don’t know why you wouldn’t try to collect the full amount from Medicaid (and commercial payers for that matter) but, unless there’s a state law I’m not aware of, I don’t see why you have to charge uninsured patients the same prices, especially when the price for them would be lower.

ETA: Do you advertise your rates? Is that the concern?

I do a lot of dental billing in my office. Every course and "guru" out there in dental billing says that you can not bill uninsured dental patients the way you described them being billed in medical. That you are supposed to charge the same fee to every dental patient, whether they have insurance or not. I think that's partly why sofamonkey is having this dilemma. I have heard lecturers make it a point to say that it is not this way in medical and that medical can be billed the way you wrote. 

I do like to read it directly from the source when people say stuff like this but I haven't had time to research our state law or a federal law about this. 

[sofamonkey]

In case anyone was wondering, we decided to not raise any fees at this time. I’m glad, and we can have a deeper discussion in August, about logistics and feasibility. Thank you all for your input, it really did help.