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MDA Chapter 63 – Financial Management in the Dental Office

The business assistant has the responsibility of maintaining complete, accurate, and up-to-date financial records in the following areas:
• Billing and collection procedures
• Financial planning
• Declaring money earned to federal and state agencies
All financial agreements should be recorded on the account ___________
ledger
_________________ is the means or process of recording, classifying, and summarizing financial transactions.
Accounting
___________________ is the recording of the accounting process.
Bookkeeping
What are the two types of bookkeeping systems used in a dental practice?
Accounts Receivable
Accounts Payable
What is the benefit of bonding insurance?
This insurance will cover a loss, and the employee can be prosecuted under the law for any such theft.
Pegboard accounting, also known as a _____-________ ___________, is a manual bookkeeping system in which all records are completed with a single entry.
one-write system
A charge slip, also referred to as a ___________ ______ or _____________, is used to transmit financial information from the treatment area to the business office.
routing slip
superbill
The _________ ______ contains information about the patient, such as name, account number and previous balance, current charges, and payment
charge slip
What should be provided with a walk-out statement?
A paid postage reply envelope, allowing the patient to mail the outstanding payment within a specific time period
Accepted fee
The dollar amount that the contracting dentist has agreed to accept as payment in full from the insurance and the patient. This amount is shown on the notice that accompanies payment of a claim.
Annual maximum
The total dollar amount that an insurance plan will pay for dental care incurred by an individual patient or family (under a family plan) in a specified benefit period, typically a calendar year.
Balance billing
When a dentist bills the patient for an amount above fee and the enrollee’s coinsurance, the dentist is balance billing and violating his/her contract with the insurance company
Basic services/basic benefits
A category of dental services in an open network dental benefits contract that usually includes restorations (fillings), oral surgery (extractions), endodontics (root canals), periodontal treatment (root planing), and sealants. (This may vary by contract.) Typically, the same coinsurance percentage applies to all services grouped as basic services.
Benefits
The amounts that the insurance pays for dental services covered under a patient’s contract.
Capitation
Compensation paid to general dentists in a closed network dental benefit plan (such as a DHMO) for providing covered services to enrollees assigned to their office.
Claim/claim form
A standard form that provides an itemized statement submitted by an enrollee or a dentist requesting payment of benefits for dental services provided.
Closed network plan
A type of dental plan where enrollees must visit a preselected or assigned network dentist in order to receive benefits.
Coinsurance
The enrollee’s share, expressed as a fixed percentage, of the contract allowance. For example, a benefit that is paid at 80% by the plan creates a 20% coinsurance obligation for the enrollee. Coinsurance applies after the enrollee meets a required deductible.
Contract benefit level
The percentage of the maximum contract allowance that the insurance company pays after the deductible has been satisfied.
Contracted dentist
A dentist who has a contract with the insurance company to participate in a network.
Contracted fee
The fee for each single procedure that a contracted dentist has agreed to accept as payment in full for covered services provided to an enrollee.
Coordination of benefits (COB)
A process that carriers use to determine the order of payment and amount each carrier will pay when a person receives dental services that are covered by more than one benefit plan (dual coverage). COB ensures that no more than 100% of the charges for services are paid when an enrollee has coverage under two or more benefits plans—for example, a child who is covered by both parents’ plans.
Copayment
A fixed dollar amount that an enrollee under certain dental plans (such as a DHMO-type plan) is required to pay at the time the service is rendered
Deductible
A dollar amount that each enrollee (or, cumulatively, a family for family coverage) must pay for certain covered services before insurance begins paying benefits.
Diagnostic and preventive services
A category of dental services in an open network dental benefits contract that usually includes oral evaluations, routine cleanings, x-rays, and fluoride treatments.
Dual choice
A program that allows enrollees to select one of two or more dental plans. (Also may be referred to as “dual option.”)
Dual coverage
When dental treatment for an enrollee is covered by more than one dental benefits plan, such as when dental services are provided to a child who is covered by both parents’ benefit plans.
Effective date
The date a dental benefits contract begins; may also be the date that benefits begin for a plan enrollee.
Eligible enrollee
An enrollee who has met the eligibility requirements under the insurance plan.
Eligibility
The circumstances or conditions that define who and when a person may qualify to enroll in a plan and/or a specific category of covered services. These circumstances or conditions may include length of employment, job status, length of time an enrollee has been covered under the plan, dependency, child and student age limits, etc.
Fee-for-service
Compensation paid to dentists based on an amount per service. A fee-for-service plan generally permits enrollees to freely select a network or noncontracted dentist to provide the service.
Health maintenance organization HMO
An entity that is authorized to issue a benefit plan in which enrollees receive all or most treatment through a preselected or preassigned dental office. The dentist receives a monthly capitation payment for each patient who selects or is assigned to that office, no matter how many services that patient receives.
In-network/Out-of-network
Services provided in a plan either by a contracted or noncontracted dentist. In-network dentists have agreed to participate in a plan and to provide treatment according to certain administrative guidelines and to accept their contracted fees as payment in full.
Lifetime maximum
The cumulative dollar amount that a plan will pay for dental care incurred by an individual enrollee or family (under a family plan) for the life of the enrollee or the plan. Lifetime maximums usually apply to specific services such as orthodontic treatment.
Limitations and exclusions
Dental plans typically do not cover every dental procedure. Each plan contains a list of conditions or circumstances that limit or exclude services from coverage. Limitations may be related to time or frequency (the number of procedures permitted during a stated period)—for example, no more than two cleanings in 12 months or one cleaning every 6 months.
Network
A panel of dentists that contractually agree to provide treatment according to administrative guidelines for a certain plan, including limits to the fees they will accept as payment in full.
Open access
A plan feature that allows enrollees to visit the dentists of their choice (freedom of choice). Also sometimes used to describe an enrollee’s ability to seek treatment from a specialist without first obtaining a referral from his/her primary care dentist.
Open enrollment
A period (usually a 2-week or 1-month period during the year) when qualified individuals (eligible employees) can enroll in or change their choice of coverage in group benefits plans.
Open network plan
A type of dental plan where enrollees can visit any licensed dentist and can change dentists at any time without contacting the benefits carrier.
Out-of-pocket costs
Any amount the enrollee is responsible for paying, such as coinsurance or copayments, deductibles, and costs above the annual maximum.
Patient’s share
The portion of a dentist’s fee that an enrollee must pay for covered services, including coinsurance or copayment, any remaining deductible, any amount over plan maximums and/or any services the plan does not cover.
Preauthorization
A requirement that recommended treatment must first be approved by the plan before the treatment is rendered in order for the plan to pay benefits for those services.
Preferred provider organization (PPO) plan
A reduced fee-for-service plan that allows enrollees to visit any dentist, but encourages them to visit PPO network dentists to minimize out-of-pocket expenses. Enrollees usually pay less when visiting a PPO dentist.
Prepaid plan
A term used to describe a benefits plan in which a carrier prepays network dentists a capitated amount for each patient enrolled in (assigned to) his/her office.
Pretreatment estimate
The insurance company’s written estimate of benefits available as of a specific date, given to an enrollee or treating dentist in advance of proposed treatment.
Primary enrollee
An individual (commonly, an employee or member of an association) who meets the eligibility requirements for enrollment in a dental plan. Family members of a primary enrollee are called dependents.
Provider
Any licensed dentist who performs dental health services for an enrollee. This includes general dentists and dental specialists.
Submitted fee
The amount that the dentist bills and is entered on a claim as the charge for a specific procedure.
Table program
A dental plan where benefits are based on a specific table or schedule of allowances or fees.
Usual fee
The amount commonly charged for a particular service by a dentist.
Waiting period
A stated period of time that a person must be enrolled in a plan before being eligible for benefits or for a specific category of benefits.

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