Advanced usage "allowed":

[fishdrzig]

Advanced usage "allowed":
An allowed Fee Schedule can be used to get more accurate estimates. If you know the UCR fees for a plan but you are not contractually obligated to follow them, then you can use the allowed fee schedule in addition to the regular fee schedule for the plan.

What if you are contractually obligated to follow the UCR fees and write off the difference, which fee schedule would be used?

[Jorgebon]

If you have a contract with an insurance company and it says you should accept certain fees as payment in full, then you should define a fee schedule with those fees for that insurance company. This would not be an allowed fee schedule, just a normal one. You should do the same for each insurance company you have a contract with. This will assure that you use the contracted fees for each insurance company. On the other hand you have the insurance companies where you do not have a contract, but you may have gotten a copy of their fee schedule. For those insurance companies you should use your standard fee schedule (your normal fees) and also make an allowed fee schedule based on the fees they normally pay. This way you know how much the plan is going to pay, and you can have the patient pay the difference up to your standard schedule.

[Jorgebon]

One of the uses we give to the allowed schedules is with Delta. I'm a Delta Premier provider and I decided not to sign up with Delta PPO. So all those Delta plans that are PPO are defined with my Delta Premier fees as the Fee Schedule and the Delta PPO fees as the Allowed fee Schedule. The patient will pay the difeerence between both schedules. Open dental will automatically calculate the percentages for each procedure and determine the patient's payment responsibility.

[sparkly]

Like Jorge said, if you have a fee schedule that's set and you don't need to keep track of discrepancies between your fees and ins co fees, you 'turn off' that feature by not letting the fee schedule be 'allowed'. The allowed feature=coverage book.

[fishdrzig]

Jorge
That is exactly what I was talking about. I only par with Delta Premier, all other Delta non-par. I only par with United Concordia National Fee for Service, all other non par. So I guess, if I set the fee schedule the way you say, then all estimates will be known ahead of time? Thanks

[fishdrzig]

Jorge

One of the uses we give to the allowed schedules is with Delta. I'm a Delta Premier provider and I decided not to sign up with Delta PPO. So all those Delta plans that are PPO are defined with my Delta Premier fees as the Fee Schedule and the Delta PPO fees as the Allowed fee Schedule. The patient will pay the difeerence between both schedules. Open dental will automatically calculate the percentages for each procedure and determine the patient's payment responsibility.

So, you have a Delta Premier fee schedule set up for every Delta patient and the ones that are PPO, you have added a PPO fee schedule also? Sorry for the confusion, but I really want to understand this better.

[Jorgebon]

That's right. I'm using version 6.0, so I don't know how it works under 6.1 yet. You set up a fee schedule with your Delta Premier fees and use it for all Delta plans, even PPO. Then you set up an allowed fee schedule for the Delta PPOs with the PPO fees. So the Delta PPOs will use two fee schedules, the Premier schedule is set as the "Fee schedule" in the "Edit Plan" window and the Delta PPO goes into the "Carrier Allowed Amounts". When you set up these fee schedules and name them (List/Procedure codes, then Edit Names, then Add) a window will appear for you to give the fee schedule a name, you need to be sure you also write "A" for "Allowed" on the box to the right of the name in the PPO schedule.
As I undestand it, in version 6.1 on up, this feature has been somewhat automated.

[fishdrzig]

Well, I thought I had this all figured out. I entered all the fee schedules needed, then when I went to the Edit Insurance plan window, the option for "Carrier allowed amounts" was not accesible? So how can I attatch an allowed fee schedule to a plan that also has a normal fee schedule? Thanks

[fishdrzig]

Nevermind, I am a stooge, I just figured out all I need to do is scroll down a little more = how embarrassing

[fishdrzig]

I am returning to this thread because I was thinking about the "allowed fee" schedule if known. If I am non par with a Delta PPO, but am par with the Delta Premier and I set the plan to the Delta Premier fee schedule and then the allowed fee schedule if this patient is with the PPO delta, what advantage does this serve me. The patient pays up front for the full fee at time of service.

[Jorgebon]

Where I practice if you are a Delta Premier provider that's non par with Delta PPO, Delta will pay you what they usually pay a PPO dentist and the patient pays the difference up to your Premier fee. Using the allowed fee schedule Open Dental will calculate the portion that Delta will pay and the portion that the patient should pay.
Jorge Bonilla DMD

[jordansparks]

OK, I have honestly had trouble following this conversation and my eyes glazed over. That's why I haven't made any comments yet. But things came to a head a few hours ago when someone, (presumably fishdrzig) called us for help. After half an hour of discussion, we the staff at OD still could not quite pin down how to set up a particular plan. So I decided to to clarify things a little better on http://www.open-dent.com/manual/insplantypes.html Look at the new red text. The very first critical decision that must be made is which of the two types to use. The red text should now clarify this.

The problem we had with the phone call was that the Dr. explained the situation as it being an out of network plan and that threw us all for a loop. But if you go by the new red text, you will see that, as far as OD is concerned, that certainly is an in-network plan because you are contractually obligated to reduce your fees. OK, so it's a PPO. The only missing part of the puzzle is how you handle the fact that the insurance will also be paying less. That's handled by the co-pay fee schedule. That will take some tweaking to decide if you should use 100% on everything, or if you should try to keep the percentages in there. But the co-pay fee schedule will definitely be able to handle the math in the end. Keep in mind that you might have to manually compute each fee in that fee schedule since you might only have the insurance co-pay rather than the patient co-pay. Problem solved. I hope my clarification will prevent future users from getting confused.

[fishdrzig]

Jordan, yes it was me who called last night. This is the only part of OD I find confusing, my eyes "glaze over" as well trying to understand this. I will try again and maybe this will offer some insight = sorry but it is important to get this right for all of us using OD and I have changed a few plans from a PPO % to cat % and now apparently will have to change it back again.

1. I am a Delta participating provider. I only par (accept) the Premier fee schedule. Any plan that pays on the premier fee schedule I set up as follows: PPO percentage and Delta Premier fee schedule.
2. There are some plans which pay only at the Delta PPO fee schedule for which the patient is responsible for the difference up to the Delta Premier fee schedule so, I do not par with the Delta PPO but because I am still a Delta par provider for the Premier plans am contractually obligated to accept the Premier fee schedule for them also. I set up the plan as follows: Cat % Delta premier fee schedule and allowed Delta PPO fee schedule. When I updated fees in the Treatment plan, it calculated that the patient indeed will owe the difference between the two plans.
3. I am a participating provider for United Concordia and only accept the NFS (national fee for service) fee schedule and do not par with the PPO fee schedule. So for patients on the NFS fee schedule, I set the plan up as follows: PPO% and NFS fee schedule.
4. When a patient has a United Concordia PPO plan, they accept assignment of benefits (United Concordia makes it this way) and the patient is responsible for the difference up to my Standard fee schedule, not the NFS fee schedule and pays me up front in full for the services provided = unlike Delta, who we bill the difference (or now could collect the difference up front since OD can calculate it for us) So for these plans I have it set up as follows Cat % Standard fee schedule allowed United Concordia PPO fee schedule

As I see it, the advantage to the PPO% is that the walkout statement will reflect a discount (write off) to the patient. I feel this is important for the patient to know.
If category % is chosen then the OD program assumes no discount calculation because there is none. So if I set the PPO plans mentioned above with the cat % and not the PPO % then the computer does not calculate a discount on the walk out statement which is the way it chould be since no discount is given to a patient on the PPO fee schedules = glaze, glaze
Hope this helps someone.

[jordansparks]

#2 is wrong. Since you are contractually obligated to reduce your fees to the Premier amounts, you must use PPO plan type. You will also need a co-pay fee schedule to handle the patient portion amounts. If this is too much work, you can indeed stick with your current strategy of category percentage with an allowed fee schedule, but then your patients will not see your regular fees on the treatment plans.

The others look correct. The important distinction when picking your plan type will always be whether or not you are contractually obligated to reduce the amount you charge the patient from your standard fee schedule.

[fishdrzig]

Jordan

Thank you for the clarification, I NOW think I understand it. It really wouldn't be too much trouble to set up a copay list since I already have both fee schedules set up and just need to calculate the differences out. I think it is important that the patient's see my standard fees on the treatment plan and still see the discount they would receive.

[fishdrzig]

Another interesting issue = when a particular plan doesn't have an annual maximum, and zero is placed in the box, the computer reads it as the patient must pay for the treatment. So I am assuming that a very large # like 100,000 should be placed in there to allow the computer to calculate against something. Correct?

[nathansparks]

Yes, just put in a large amount, 100,000 is often used. The one issue with the copay fee schedule is that it may be complicated to come up with the copay amounts. I wam willing to work with you on this til we get it working right for you, and define any hurdles.