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3.4 Setting Up a Billing and Collections System
To account for income received from services rendered to patients, clinics need
a billing and collections system. Table 1 shows patient-income categories and
how these fit into a billing and collections system.
Table 1: Billing and Collections
| Patient Category |
Charge |
Billing |
Collections |
| Self-pay patients |
Charge per procedure |
ADA procedure codes* have a charge
assigned, or a per-visit fee is established |
Collected at time of service |
| Third-party fee-for-service (Medicaid,
Medicaid managed care plans, and other insurance) patients |
Charge per procedure |
ADA procedure codes with full charge
assigned (UCR), transmitted electronically, if possible |
Periodic bulk payment checks (itemized) |
| HMO fully capitated patients |
Monthly per member per month |
Submit ADA procedure codes to HMO
as proof of activity, but not paid on these |
Monthly check from HMO for all assigned
patients, whether seen or not |
| HMO partially capitated fee-for-service
patients |
Monthly per member per month plus
charge per service not in cap |
Submit ADA procedure codes to HMO,
but paid only on services not in cap |
Monthly capitation check for all
assigned patients; check for services above cap on patients
seen |
| Patients with low-incomes and without
insurance |
Charge per procedure or per visit,
usually on a sliding fee scale |
Use federal poverty guidelines
to establish sliding fees per visit or procedure; discount
based on patient income |
Collected at time of service |
*See the ADA
Web site. National
and regional usual, customary, and reasonable (UCR) cost per service
information by CDT codes can be obtained from the National
Dental Advisory Service.
As part of their billing-and-collections system, clinics need a library
of procedures by code, with appropriate fees attached. This library
is activated to generate bills.
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