Cigna HMO setup.

[ForrestGumpDDS]

Hi all, I desperately need your advice. Looks like I am doing something wrong.
I have a Cigna DHMO plan that I need to set up.
The plan features 2 fee schedules. One is a common fee schedule for all members. It has a name "Supplemental fee schedule" (let's call it SFS for short). The other one is named "Patient charge schedule" (let's call it PCS) and looks like this schedule's amounts vary from the patient to patient.
The schedules are suppose to work like this: I charge the patient amount from PCS, however, if SFS amount is higher for that particular code - then I bill the insurance for the difference.
Plus, in addition to that I charge the patient a fixed co-pay every visit.
Ho I set it up:
1. I go here - http://www.opendental.com/manual/insplantypes.html and follow the instructions on the bottom:
HMOs with supplemental payments and copays (very common in Texas)

These must be entered as Type PPO. Set benefits to 100% for all categories. Create a 'Copay' fee schedule with patient copays. Also create a 'Normal' fee schedule with insurance supplemental amounts + patient copay for each procedure. Make sure to put 0 if there is no fee, or else the patient will get charged the UCR fee.

2. I called the support and double checked that PCS is supposed to be entered as "co-pay" type and SFS - amounts added together with PCS amounts (sum) and entered as "normal" type.
3. Entered 2 fee schedules and did the math to calculate the "normal" schedule.
So now for example for the D2391 I have following:
PCS=$45, SFS=$30. Cigna DHMO (co-pay)"=$45, "Cigna DHMO (Normal)"=$75
for D0140 and D0220:
PCS=$0, SFS=none. Cigna DHMO (co-pay)"=$0, "Cigna DHMO (Normal)"=$0, that's right, same for both...
4. I add an insurance plan to the patient and name it Cigna DHMO
5. Plan type change to "PPO percentage"
6. I assign Cigna DHMO to a "Fee schedule" from the drop-box.
7. I assign Cigna DHMO to "Cigna Co-pay Amounts" field below.
8. I change all benefit information values to 100% and close the window.
9. I create an N4391 code and in both of the copay and normal fee schedules for Cigna DHMO add $3.50 (that's how much it is numerically), also mark the code as "do not usually bill to insurance".
So, I am good to go, right?
Now, here's a problem. I want to do this patient a limited exam, PA and one-surf composite for the tooth #14
I added D0140, D0220, D2391 and N9430 to the appointment and set it complete.
I create a claim and what I see in the claim is the D0140 and D0220 are written off completely to $0, but the D2391 shows write off -$75 (from my fee which is $150 if it makes any difference), the insurance estimate is $5 and patient portion is $70.
The co-pay code adds $3.50 as expected.
Nevertheless InsEst (not from the claim window, but in the account window) shows $182 (in the claim window it was $5).
It is suppose to be Patient's portion $45 for a filling plus $3.50 (co-pay) totalling $48.50. Looks like I should not have added up these numbers for a "normal" schedule.
I tried to revert the code amount in a "normal" schedule for D2391 to $30 (from SFS, w/o adding values of SFS and PCS), however it did not give me a desired result either.

How is patient portion calculated in this scenario? "Normal" amount minus "Copay" amount? So that part of the tutorial is for those plan that deduct patient charge from the supplemental schedule?
In my case I collect from the patient according to his PCS and bill the insurance the difference from PCS and SFS. If PCS amount is higher - then that's the only payment I get.
Please see the screenshots for visualizing.

...

[bpcomp]

I apologize in advance, I did not thoroughly read your post but glanced over it.

If your issue is only for this one procedure then... In the code setup for composite filling on posterior teeth there is an option to apply the alternate benefit of an amalgam restoration. You can over ride this setting in the insurance setup by checking the "Don't Substitute Codes" option in the insurance setup.

[ForrestGumpDDS]

If your issue is only for this one procedure then... In the code setup for composite filling on posterior teeth there is an option to apply the alternate benefit of an amalgam restoration. You can over ride this setting in the insurance setup by checking the "Don't Substitute Codes" option in the insurance setup.

Thank you, bpcomp.
I did miss that out, by default that box is not checked. After applying the change (do not substitude codes) the behavior did change and the patient portion is now calculated properly. However the insurance portion does not look right. The insurance only suppose to pay if the patient charge is less then the supplemental amount for the same code and only pays the difference.

I experimented with assigning "normal" fee schedule an amount from SFS (as oppose to SFS+PCS as it was suggested in tutorial and done on all the other codes except for this experiment). It for some reason reduces patient's portion to the amount of SFS and this is not right either, because the patient should be responsible for PCS.

I came to conclusion that the "normal" fee schedule in my case should be set up by adding one logical step. I should check if the supplemental payment is equal or greater than patient charge amount then I should add SFS to PCS. If the supplemental payment is smaller than PCS - I should enter PCS value into a normal schedule. In this case insurance portion will be 0 and patient portion will not be affected.
So I tried that approach and got the result that I want to see.

The only thing that puzzles me is InsEst amount. I have no idea what to do with it.

[ForrestGumpDDS]

bump. Still have not figured it out.

[Dwayne]

The insurance estimate that you are seeing includes the write off, which is why it looks so high. When you post the insurance payment and create the writeoff, the balance remaining will be the patient portion ($45 + 3.50).

[ForrestGumpDDS]

Thank you! That makes sense now.
I have another question, I noticed a very strange behavior in OD.
Let's say ins. suppose to issue supplemental payments for the procedures and the pt. has a "0" co-pay.
I set those procedures in OD as follows:
1. Create 2 identically named plans (one Normal, one co-pay type) and assigne them to the pt. from add an insurance window.
2. Select 100% coverage for all the procedures and check "Do not substitute codes".
3. Add a D4341 code and a custom created N0001 code for co-pay to the appointment.
4. In the code section assign values as follows: Co-pay type sched. - "0" for both codes (in this type $3.50 copay is made by ins company). Normal - $81 for D4341 and $3.50 for N0001. Double check that both of the codes do not have "do not usually bill to insurance check marks" in the properties.
5. Strange behavior. When the appointment is complete and the claim is created only D4341 is set to be insurance responsibility. N0001 goes to the pt.'s balance. Why? Is that something that needs to be looked in my system or this is a "expected" behavior from the N-code?

[Dwayne]

This is expected behavior for the following reason. N0001 is not technically a ADA code, so your percentages in the insurance plan (100%) do not apply to the code. In essence, Open Dental is being told the insurance won't pay for it because N0001 isn't categorized as a preventative code (for example) and therefore the balance goes to the patient.

In order to have N0001 reflect as the insurance responsibility, you have two options. Either add this code in the "Other Benefits" section inside the insurance plan with 100% coverage, or go to Setup > Insurance Categories and add that code to an insurance category which already has coverage.

[ForrestGumpDDS]

OK, I will try this tonight.
Just a though about the tutorial. I think it applies to the situation when both the insurance AND the patient have their set fees that are due upon procedure completion independent on each other. That's why you suppose to add patient's co-pay to supplemental fees and put the resulting value in "Normal" schedule.
In my case (Virginia, Cigna DHMO) supplemental schedule number is the amount which Cigna will match if the patient's portion is less than that. And what I do when setting up a "normal" schedule - just putting the higher value (between patient's copay and supplemental schedule). So if pt's co-pay is higher then numbers in "Normal" and "Co-pay" types will match and insurance portion will be "0" when OD takes the pt.'s copay off the "normal" schedule amount. If pt's copay is smaller - then it's straightforward. Pt. owes their co-pay and the insurance picks up the rest up to a value of Supplemental amount schedule. Took me some time to understand.
Do you have any tutorials how to calculate "normal" fee schedule in a quick way? What I do right now is creating and exporting from OD the "co-pay type" fee schedule for the group into a spreadsheet, copy supplemental amounts to the next column, creating a formula for evaluating values in co-pay and normal cells for one code with result output to a third column cell and apply the formula to the whole third column. Then delete the co-pay and normal columns, save and import the values to normal schedule into OD. Is there any easier way to do it?
Thank you.

[Dwayne]

Unfortunately not. That is the fastest way.