Two key pieces of information are needed to predict patient care revenue for each payer source: (1) number of patient visits and (2) average reimbursement per patient visit.

Number of Patient Visits

The interactive budget planning spreadsheet (click on toolbox icon) estimates the number of patient visits by payer type using the anticipated number of patient visits for the year and the percentage of patient visits for each payer type. Payer types may include patients covered by Medicaid or other public insurance programs, private-pay patients, and patients covered by private insurance policies.

Clinics that are expanding can use their past experience (financial reports) to help generate their estimates. New safety net dental clinics with pre-existing medical clinics have a historical payer mix that can be adjusted for the percentage that is funded by Medicare, which does not cover oral health care. New clinics with no pre-existing medical clinics, however, must rely on information from other sources, such as safety net dental clinics that are willing to share information.

Average Reimbursement per Patient Visit

The average reimbursement per patient visit by payment source is the product of a number of factors, including the following:

• The clinic’s fee schedule
• The structure of the sliding fee schedule and the minimum fee level established
• Medicaid rates and coverage for the state
• The structure of the state’s SCHIP program (in Ohio, SCHIP-eligible children receive care under Medicaid)
• Patient mix by age
• Service mix (e.g., emergency care, diagnostic and preventive care, restorative care)
• Managed care
• Eligibility for cost-based or prospective Medicaid reimbursement (e.g., federally qualified health centers, look-alikes)

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