Positive Insurance Adjustments / PPOs

[hjoesaar]

I have a problem that has plaqued us since the early days of OD. Perhaps there is an answer now.
1. We submit an eclaim to insurance with UCR fees althought it is a PPO.
2. We receive a check that actually pays more thant the PPO fee schedule. When we post this it shows that the patients actually has a credit, so we...
3. We need to make a POSITIVE insurance adjustment to reflect the above.

When the Patient receives the statement and sees this they get pissed off! When we explain it to them they understand but it seems fishy. This totally sucks for us and it happens on a consistent basis. Yes, we are up to date on our PPO fee schedules but every group is different.

How can we adjust the claim so that the above isn't a problem?

[jordansparks]

Hmm. Interesting. The thing to do, of course, is to simply change the procedure fee. I'm not talking about any estimates or adjustments, but the actual procedure fee. The patient won't even notice, and it will seem less fishy than an adjustment of some sort.

I haven't heard this complaint before (or I've forgotten it). It's one more reason why we will be moving to a different way of handling PPOs. We're going to let offices put their regular fee and writeoff what insurance doesn't pay. This is how most other dental software handles it, and we are getting more and more pressure to make this change. I've moved it up on the future versions page.

[Jorgebon]

I hope the plans to change the way PPOs are handled doesn't mean you're going to eliminate all the existing ways of using different fee schedules and copay schedules. I'm specially fond of the allowed fee schedules. I still haven't seen a plan we can't give exact or very accurate estimates for using all the existing tools. If you could make additional or alternative tools without eliminating the existing functionality it would really be great for everyone. One of the greatest advantages Open Dental has over all other software is that with multiple fee schedules you can give exact estimates and charge the patient the day he/she receives treatment.

Jorge Bonilla, DMD

[jordansparks]

I'm glad it's working well for you. No, there would be no change to the current functionality. The new functionality would really be a number of smaller additional features. Approximately:
1. Better way of identifying 'types' of insurance plans, such as PPO.
2. Reworking writeoffs to be adjustments. This moves them from income to production, where they belong.
3. Discount field added to TP. This might be one way of showing the fee reduction.
4. A way to indicate preferences for PPO calculations on a global basis
5. A way to indicate preferences for PPO calculations on a per-patient basis.
6. Automatic calculations.

5&6 could be done to make a "quick and dirty" solution as an option. It would take longer if we have to wait for 1-4 first. Of course, all of this is speculation.

[hjoesaar]

Jordan,
Man-O-Man-O-man those changes to PPO's would make me happy! It would really make my front desk happy too! Beyond what I stated in my first message we are having another problem. At the end of every month we print out our production report and I send it to my accountant. At the end of every quarter we sit down and review. The thing is, when I print out the same reports for previous months, they're different! That upsets my accountant pretty badly. Production, writeoffs, adjustments, collections... everything is different almost every time we print it out! these changes usually aren't big (<$20) mostly and they don't happen every time, but it's a big deal. (embezzlement?) I think a lot of this is due to how PPO plans are handled in OD. I have spent hours going over these changes and I've got more headaches than answers. I haven't even bothered with asking OD support to help figure it out because it's overwhelming. Anyway, we would love it if you speed up those PPO changes!!

[premier1888]

I've had the exact same thing happen, since mine's a new office and some insurances we weren't sure what they would pay and they ended paying more than the estimates. I've had to make positive adjustments.
Anyway, it would be great if these changes to the program allow us to go back and change the estimates to actually reflect what the claims and EOBs actually say.
BTW, how do you set it up so that a certain plan's fee schdule shows the fee for a composite, let's say, but also remembers the allowed fee, so that it is automatically refected in the estimate?

[Jorgebon]

You need to make two fee schedules for this situation. The first one is the fee you expect for every procedure (total ins plan plus patient pays). Then you make another fee schedule and classify it as "allowed fee schedule". In this one you put whatever the plan normally pays for each procedure. When you define the patient's insurance, make sure you select the first fee schedule. Then under "carrier allowed amounts" you select the second one you made.
This is great for those PPOs you haven't signed a contract with. For example, we never signed with MetLife, but we know how much they pay because we've been treating MetLife patients for a long time (and they keep sending me contracts with the fee schedule all the time). So we have our fee schedule for what we want to get paid in total and we have a MetLife allowed fee schedule. Open Dental will take in consideration the percentages and deductibles (by the way, they have a great fax-back feature where they send you all the info you need on the specific patient's plan), and the patient portion is calculated.
Another use is if you are a Delta Premier provider and see Delta PPO patients. Your main fee schedule there would be Delta Premier and your allowed would be Delta PPO allowed.
Jorge Bonilla, DMD

[hjoesaar]

Hi Jordan,
Can you give me an idea of when these PPO changes might be made? thanks!

[jordansparks]

It's currently at the very top of the future versions page. So there's reason for hope. But no feature is ever promised at any particular time. Programming is simply too unpredictable for me to be able to give any time estimate.

[Yorek]

Since the whole idea is to have accurate accounting to keep the patients and front desk happy..
Can you move up the Alternative benifit calculation as well.
It still seems buried down your To-Do List.

We still have to manually figure how much the patient owes each time we do a posterior composite or add porcelain on a molar crown. This takes time and adds a layer of frustration for my secretary.

We just need a 'Box' in the Edit Proceedure Codes called 'Alternative Fee'
Let OD figure the actual amount the insurance will cover based on the % of this fee..
..But charge the patient based on the higher allowable Fee.

Sound simple, but the programing may not be.
Thanks.

[jordansparks]

Work has begun on the new PPO features. Almost done with the TP estimating part of it. Keeping track of amounts on pending claims is where it's going to get really difficult. Right now, the insurance portion plus the patient portion always add up to the procedure fee. In the new way of doing things, there will be a portion that is covered by neither the patient nor the insurance company. Trying to convey that information on the Account screen may be complex. But we'll see what it looks like soon.

[dand]

while your are doing these adjustments for the PPO, would this be a good time to correct the Deductible Calculations: ie"Allow global default for applying deductible before percentage"

[Yorek]

Jordan, if your basic formular is..

>Insurance portion
+ The patient portion always add up to the
------------------------------------------------
= Procedure fee (CoPay)

It's not possible to accurately figure Alternative Benifits this way.

Because with Altern Benifits there are 2 proceedure fees
and we'd like to bill the patient the HIGHER allowed fee!

Therefore the Procedure FEE has to be IN the formular
..NOT a variable result
based on how much the insurance is willing to pay.


Shouldn't the formular should look like this..

> The Highest allowed proceedure Fee, (eg Resin not Amalg)
- Insur Benfit
-------------------------------------------
= Patient portion. (CoPay)

This way the CoPay is based on the fee we want to charge
Not how much the the insurance is going to pay, which is the Variable.

I have the feeling you already know this and it's me that's missing something.

Thanks for a great program.

[jordansparks]

The math is SOOO much more complicated than the previous post implies. I'm staring at pages and pages of calculations. Don't worry, I know what it's supposed to do, it's just that it's the sort of thing that takes days/weeks/years of intense concentration to get it just right. Serious progress is being made.

[jordansparks]

New PPO features are done. Just finishing up the reports now.

[Nate]

So sounds like there may be a new way to fix the cases where a PPO pays based on standard fee rather then PPO fee.

However... as Jorgebon had mentioned we already have found ways around this utilizing the current features. Obviously the quickest way is to make that mysterious positive adjustment... that could have the patient questioning what was going on. You could just simply explain we estimated and insurance paid based on our standard fee schedule.

Or if you want the account to look perfect for those hard to deal with patients it only takes a couple minutes to delete the claim, change the treatment completed to treatment planned, then make sure you 'dont' use the PPO fee schedule, then update treatment plan fee schedule. Go back and set procedures complete and make new claim. Then everything should now balance out.

But chances are the next claim that patient has will probably use the PPO fee schedule, at least that is what I have found. We are up to date with Insurance PPO's, but they do occasionaly pay our fee schedule and we will do one of the above to fix the account.

I am interested in how this new method will work and hope it is as straight forward as the existing method. Again hope we can still use patients insurance fee schedule rather then just use ours and write off the difference every time.

[jordansparks]

Posterior composites: DONE
Deduct before percent: DONE

[cneelley]

I haven't seen the final result yet, but I thought I would say that most insurance companies separate posterior molar composites from posterior bicuspid composites. They have the exact same code, 2391, 2392, etc. Most companies will pay for bicuspid composites, but not molar composites. This has what has kept me up until now from using the alternate fee schedule feature.

Dr. Neelley

[jordansparks]

A new twist on posterior composites that I didn't think about. No problem. We'll get a solution for that too.