Deductible problem

[mfdental]

Hello,
My patient has Assurant insurance, and they have a $50 deductible. This deductible also applies to single PA's.

In the "other benefits" section, I added the individual deductibles like this:
Level: Individual
Type: Deductible
Category: D0220
Amt: 50
Time Period: Calendar Year

Here is the problem: The patient has already satisfied their deductible for this year. But if I treatment plan D0220, Open Dental states that the patient still has to pay the deductible. If I treatment plan a filling, then open dental does not make the patient pay for the deductible. It seems like when you edit the other benefits section with a deductible, it counts it as a separate deductible that does not count towards the cumulative "General Deductible". Is there a way around this?

I have the latest version of Open Dental.

[Dwayne]

By using the "Other Benefits" section, you are giving Open Dental an exception to the rule. Therefore, it ignores the rule completely when it comes to code D0220. The only other option is to include a $50 deductible for all Xrays, but I'm sure you don't want to do this. Is it safe to say there would be other procedures on an appointment other than just the PA, which would be able to reflect the deductible anyway? This may be a non-issue if that is the case.

[mfdental]

Sorry responding so late to this answer. I think Open Dental making an exception to the rule is incorrect. It shouldn't add its own new deductible just because you specified that a certain other procedure has a deductible. It should be referring back to the original deductible limit, and checking to see if it has been satisified or not. There are no insurances out there that has two separate deductibles that is dependant on procedure. Using "Other Benefits" to let open dental know that a deductible applies to a certain procedure should count towards the cumulative deducitible for fillings, crowns, etc. It should not be its own deductible.

In terms of other procedures... the point is I shouldn't have to be constantly double checking the calculations for these patients. I should just be able to set the deductible to 50, and set it so that a single PA would count towards the general deductible. That way if they did 5 PA's, which satisify the deductible, then when they do the filling, the computer will not charge them the deductible.
Or another scenario: If they did a filling that satisfied the $50 deductible, and a month later they come in for a PA, the computer shouldn't be charging them the deductible.

In my case, the computer is double-dipping the patients for a deductible each time, and this is unacceptible. It might be $50, but patients can get annoyed or angry at that sometimes.

-Jason Chao

[Dwayne]

If you have a $50 general deductible, and then add an additional deductible to a specific procedure code in Other Benefits, you are essentially telling Open Dental there are two different unrelated deductibles. The procedure code you type in will have it's own, separate deductible that needs to be satisfied.

[mfdental]

So is there a way for me to let open dental know that code D0220 (Single Pa) will apply to the general deductible? I do not see any options for the program to do that.

I have the same issue for several other treatment procedures.
Examples are Emergency/palliative treatment D9110, Periodontal Maintenance D4910
For these procedures, some insurances charge the deductible, and some do not.

I do not want to have my receptionist manually key in the deductible every time the patient comes in. Its too hard to keep track. I would rather it be set it up once, and have it automatic.

I think an easy way for you guys to fix this is to make it so that if you type in a specific procedure in the "Other Benefits" section, you can specify that the procedure will count towards the general deductible, rather than creating its own deductible.

[jsalmon]

I did a quick search and didn't see this in our Feature Request system. You should do a more thorough search and see if someone has already asked for this type of functionality and pledge an amount or throw some votes towards it or if it doesn't already exist, add it as a new request yourself and try to spread the word. This way we can keep track of this feature and see how many other people would like this functionality added. http://opendental.com/manual/featurerequests.html

[mfdental]

Well, I looked, and this was mentioned in request#313, but it was listed as COMPLETE.
The user comment on 03/09/2009 mentioned the same exact issue as me... here's a quote: "PA's are now being classified as restorative by some insurance companies"

This was noted as "Done in version 6.7", so can someone please tell me how to do this?

I need to classify PA's as restorative so that it will count towards the GENERAL deductible

Also, open dental classifies periodontal maintenance as preventative, so it does not count towards the deducitble... however, I need to be able to change the periodontal maintenance to perio classification sometimes because some crappy insurances actually do count a deductible towards the maintenance.

[bpcomp]

This might be too much hassle but you might be able to go into Setup/Insurance Categories and adjust the categories so that that procedure code falls under the category you need. The problem is that this is system wide an effects all plans. So on all plans where PA's are not restorative, but are preventative... you would need to override and say that for that procedure code there is no deductible.

[Dwayne]

This is correct. You will need to re-categorize that procedure code in Setup > Insurance Categories, and yes it is system wide if you make that change.

[mfdental]

That's does not make sense, because only about 10% of insurances charge the deductible for random procedures, such as PA's or Perio maintenance. If I did it your way, It would add extra work for 90% if my other patients. My whole reason for this issue is I want to make life easier for the other 10% of my patients. I do not want to have to MANUALLY change the fees for 10% of my patients that has a deductible for single PA's or Periodontal maintenance.

Isn't it a simple fix to make the deductible specifications in the Other Benefits section link to the overall cumulative general deductible? In fact, I think it is a bug that creating a deductible in the Other Benefits section will create an alternate deductible separate from the general deductible. I never heard of insurances that have two separate deductibles dependant on procedure. They all just have one overall general deductible, and once that's satisfied, they get full benefits.

[bpcomp]

If there is another way to do it then I'm not aware of how to do it and yes it would be a lot of work to do what I suggested. You might take a look at feature request #1324 or make a new feature request to get that into the OD system.

[mfdental]

That feature request wouldn't work either, because its asking for a deductible checkbox for categories. Open Dental categorizes single PA's together with BW, and FMX, so it wouldn't work in that respect. Open Dental also categorizes Perio Maint. in the same category as preventative procedures, such as prophy. So a checkbox wouldn't work there either.

I dont think it should be a feature request. The feature is already there, its just broken.
You can already specify specific deductible for exact procedures. They just need to make it link to the general deductible, rather than make a separate deductible.

I've been doing all my insurance claims myself for this last year, and I have NEVER heard of an insurance that has two separate deductibles depending on the procedures done. They usually just have one deductible. They dont have a $50 deductible for restorative, and a separate $50 deductible for crowns, etc.
The fact that the "other benefits" section creates a seperate deductible is completely broken in my opinion.

[bpcomp]

I can totally understand your frustration with how OD handles deductibles and from several interactions I've had with the OD team on issues critical to our office, you should probably call support and discuss the issue with them. However they will probably direct you to create a feature request for the issue anyway. It seems that is the way they handle most changes to the program be they new features or changes/fixes to existing features.

The part of feature request #1324 that I was referring to was in the comments section asking for check boxes on individual procedures as well as categories. It might be better to make a separate request though.

[mfdental]

Yes, I think a major functionality of practice management programs is to help calculate insurances. The fact that I have to manually alter the insurance calculation for 10% of my patients is a serious flaw in my opinion. It doesn't make sense to add an extra steps for my staff:
1. Check insurance notes for every single patient to see if they have special deductible specifications.
2. Cross check total remaining benefits to see if their deductible has been satisfied or not.
3. Manually key in the deductible in the procedures.

I dont think very many people are aware of this issue because most Dentists do not do their own claims. They leave it to their staff. Maybe the staff do not tell them, or the staff just bills the patient after receiving the EOBs. When this happens, patients get upset. We lose money, because we do not collect up front, or lose patients because they're mad that we didn't tell them about the deductible earlier on.

[mfdental]

Okay, its been a while since I've received a response in this email... I kept telling the staff that this is a bug, but they wont believe me. Now I think I can prove that this is a bug in the system.

Here's my example:
Patient's insurance has 100% coverage for preventative, and 80% coverage for fillings. However, they have a $50 total deductible that applies to ALL procedures, including preventive. So in the upper right box of the "Edit Benefits" section where you enter all the percentages for each type of procedure, I put in the $50 deductible for Diagnostics, X-ray (if different), and Routine Preventive.
Originally, when I did the treatment plan, it calculated it correctly. It said that the filling would have a $50 deductible, and the Cleaning would have $0 deductible, since the filling would satisfy the deductible already. However, things went differently when I actually performed the procedures:
First visit I did a filling, and the patient was charged the $50 deductible, along with their 20% copay of $20. This was calculated correctly, and also estimated correctly on the tx plan.
Second visit, I did a new patient exam, x-ray, and cleaning... The deductible should have already been satisfied from the filling appointment, HOWEVER, the computer still calculated that the patient owes another $50 deductible. This doesn't make sense, because they already satisfied their deductible for the filling appointment, and the saved treatment plan also showed that they owe $0 deductible for the cleaning appointment.

If this isn't a bug, then I dont know what you guys consider a bug... There's clearly something wrong with this, since the treatment plan said one thing, and then the submitted claim says another...

Also, anyone who knows anything about dental insurance knows that they do NOT have a separate deductible for each category. You NEVER see a patient with a separate $50 deductible for cleaning, separate $50 deductible for X-rays, separate $50 deductible for exams, separate $50 deductible for filling, etc... They just have ONE global deductible, and once that first $50 is paid for, they get the full benefits. For some reason, Open Dental tries to create a separate deductible whenever you want preventive procedures to apply to the global deductible.

[Jorgebon]

This is how we do it in our office, and it has worked fine for us:
1. Classify the plan as "Category Percentage".
2. Enter the percentages for each category (100, 80 50 or whatever it is).
3. Enter the general deductible ($50) and annual max if any.
4. Enter $0 in deductible for Diagnostic and Routine Preventive.
5. Enter $50 in deductible for X-Ray.
6. Go into the Other Benefits area and add exceptions (x-rays that do not pay deductible) by choosing:
a. Category- None
b. Proc Code- D0274
c. Type- Deductible
d. Amount- $0
7. Repeat step 6 for other codes where deductible is not paid.
8. When you set complete procedures with deductible, they will appear in the account module BUT UNTIL YOU CREATE THE CLAIM YOU WILL HAVE THE PROGRAM RECALCULATE DEDUCTIBLES ON OTHER PROCEDURES IN THE TX PLAN MODULE. After you create the claim for the original procedures, it will recalculate one more time taking into account the deductible met by the patient, and the amounts should be correct (they are when we do it in our office).

Jorge Bonilla, DMD

[mfdental]

Hello Jorge,
Thanks for your input on this, but it does not work. I did exactly what you've done, and even though the patient only has one $50 deductible, it still charges a separate $50 for the filling, and $50 for the x-ray. So in reality, Open Dental is trying to charge $100 deductible total... I've had cases where the patient gets upset because the receptionist would ask them for a $50 deductible, when they already paid the deductible. (This is also calculated after submitting the claims, so I'm doing it your way also).

[Jorgebon]

If it doesn't work for you, then there must be something wrong in your database or your version is older than mine. I'm on version 13.1. Mine works fine and we have multiple patients of this type. The software calculates correctly in our office. I suggest you recheck it step by step and see if you can find something different. As I said before, in our case when we "set complete" the procedures which had the deductible applied in the treatment plan, the software temporarily assigns the deductible to other procedures. Once we create the claim it recalculates and then it takes into account the deductible paid by the patient removing the temporarily assigned deductible. I suspect something you are doing differently is blocking the recalculation that credits the deductibe paid.
This is what one of these plans look like:



Jorge Bonilla, DMD

[mfdental]

Jorge,
I do have the latest version. Mine is completely opposite from you. In the treatment plan module, it calculates correctly... however, once you submit the claim, it tries to charge that extra deductible. I messed around with it a bit, and I noticed if you did the x-ray first, and then the filling afterwards, it calculates the deductible correctly. However, if its the filling first, then it will try to recharge the deductible for the X-ray.

[mfdental]

I didn't realize you could send pictures through html links... here's an example I just created, using a test patient account... there's clearly a bug here, since the treatment plan module calculated everything correctly, but once you submit the claims, it doubles up on the deductible charge....

[Jorgebon]

I tried it like you said with the fillings before the x-rays and there is definitely a bug. When you set complete other procs on another appointment before the x-rays it will calculate the deductible twice. I guess I hadn't noticed it before because we almost always complete x-rays before any fillings. I hope somebody at Open Dental is reading this so they know you found a bug.
Jorge Bonilla, DMD

[Dwayne]

Thank you for the detail on this issue! This is very helpful. I would be happy to document this and pass on the information to the the programmers. Could you please call in and ask to speak to a support tech in order to get this started? I would record the information on your account right now, but I cannot identify you from your user ID. If you like, you can email a copy of this screenshot to service@opendental.com with your account information, and I can document it that way as well.

[mfdental]

Thanks Dwayne, I will email you the screenshot.

[mfdental]

It seems the programmers are unwilling to admit they made a mistake... they said I need to do a feature request and its not a bug.. this is pretty ridiculous. I'm pretty sure its a bug if it calculates the deductible correctly in ALL instances, except where you submit the claim for the filling first, and then submit the claim for the x-rays afterwards. Here's another photo that shows all the other instances where it actually works. Its pretty upsetting for them to brush this off as a "Feature Request"

[Jorgebon]

I agree, this is indeed a bug. This is not a new feature that we would like added to the program, it's something that was supposed to be working a long time ago and right now it only works part of the time. I hope they reconsider and treat malfunctioning features as something with more priority than features we would like added.
Jorge Bonilla, DMD

[jsalmon]

I'll agree with my fellow programmer that this is a feature request.

The treatment plan shows insurance estimates (as well as deductibles) as if you were to submit the entire treatment plan to insurance at once. You're basically asking the treatment plan to guess at how many claims will be sent.

As my other coworker stated earlier:

If you have a $50 general deductible, and then add an additional deductible to a specific procedure code in Other Benefits, you are essentially telling Open Dental there are two different unrelated deductibles. The procedure code you type in will have it's own, separate deductible that needs to be satisfied.

With that bit of information, here is what the program sees in the four scenarios you posted above:
One claim, D2394 first:
D2394 - falls under your general $50 deductible and no other deds are applied. See test 16 in http://opendental.com/manual/unittesting.html "Multiple deductibles for categories should not exceed the regular deductible"
D0210 - fully covered. (If you were to TP this same code again, you'll see a $50 ded applied to that one because the special diagnostic ded set up has yet to be met)

One claim, D0210 first:
D0210 - falls under both general and special deductible and both are satisfied.
D2394 - typical coverage applied with no deductible.

Two different claims, D2394 first:
D2394 - falls under your general $50 deductible.
D0210 - falls under your special diagnostic deductible and now both have been satisfied and will not show up on further procedures.

Two different claims, D0120 first:
D0210 - falls under both general and special deductible and both are satisfied.
D2394 - typical coverage applied with no deductible.

Now I'm not an insurance guy so I don't know the scenario where these special deductibles are required to work the way they do but I'm sure they are (and have been) like this for a reason. So from my perspective, you're wanting the treatment plan to reflect breaking up its treatment plan into multiple claims (maybe by priority?). This is not how the treatment plan was originally designed, hence the feature request.

It's not that we are unwilling to admit mistakes (God knowing we make them often. Just use an early beta release some time ). It's just that we don't want to break it for whoever needs the special benefits to act how it's acting right now to please whatever situation that they have.

[Jorgebon]

So, would the correct way to define a plan with a $50 deductible that applies to all treatment including diagnostic, x-rays and preventive would be to enter $50 in the general deductible and leave blank the fields for Diagnostic, X-ray and Preventive deductible?
Jorge Bonilla, DMD

[jsalmon]

Absolutely. If there's no special deductible required for a category or a specific procedure, don't add it to Open Dental. Insurance is already complicated enough.
If in fact the insurance requires this unique deductible and you think Open Dental is sending the claims incorrectly, we'll need clearinghouse information, carrier information, and the rejection letter / EOB. That would be the most compelling information to dictate that this is in fact a bug.

[Jorgebon]

I found the way to define a plan that has deductible for everything (including x-rays) but excluding exams and preventive. You enter the deductible amount in the general deductible field, then leave blank deductibles for diagnostic and x-ray ($0 is not the same thing) and put $0 for preventive deductible. Then you go into the "Other Benefits" section and add $0 deductible for D0120, D0140 and D0150.
As for the original poster's quetion, a plan with a general deductible that also applies to D0220 and D0230, I found that we can define it as follows:
First, go into Setup/Insurance Categories and separate X-Rays from Diagnostic by assigning spans D000 to D0199 and D0400 to D0999 to Diagnostic. Leave X-ray spans as they are (D0200 to D0399). As it's set up by default, x-rays are a subcategory of diagnostic which makes it impossible for the original poster to get the right results.
1. enter deductible amount in the general deductible field
2. enter $0 in the Diagnostic and Preventive fields. Leave X-ray deductible field blank.
3. Go into Other benefits and enter the exceptions with $0 deductible on all other x-ray codes that are not PAs.