PPO with co-pays.

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ForrestGumpDDS
Posts: 177
Joined: Fri Oct 14, 2011 3:31 pm

PPO with co-pays.

Post by ForrestGumpDDS » Thu Oct 31, 2013 12:20 pm

Hi all,
I have an issue that I feel should have a simple solution, however I am asking for your hands.
We signed up with Federal Employees Plan and one of them has following features:
  • The insurance has a fee schedule (they call it maximally allowable charges, or MAC)
  • Pt. pays a co-pay of $25 for all and any procedures listed in MAC list during the visit
  • The insurance pays 100% of MAC deducting $25 (which is suppose to be paid by the patient) from the check
  • Any procedure that is not on the list - not covered, the pt. pays my office fees
Ho do I set it up in the system? It's more like a deductible behavior rather than a co-pay. Like a deductible that the pt. has to satisfy at every visit. If I assign a co-pay fee schedule, the co-pay will be applied to all the codes and added per each procedure. But I only need it to be applied once. If I set the plan as PPO %-age or Cat. %-age and tell my receptionist to add a co-pay code with assigned value of $25 then the pt. will be left with ballance of $25*(number of appointments) after insurance payments are entered.
The only solution I see is to set PPO %-age plan to 100% coverage, Normal fee schedule st to MAC values, AND override one of the procedures manually with subtracting $25 from insurance estimate. Then it'll leave the account with $25 balance upon completion and after the insurance pays the account will have zero balance.
Is there any way to automate it?

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Jorgebon
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Joined: Mon Jun 18, 2007 2:25 pm
Location: Mayaguez, PR
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Re: PPO with co-pays.

Post by Jorgebon » Thu Oct 31, 2013 2:41 pm

This is what you could call a per visit copay (although I agree that it's more like a daily deductible). We have this kind of plan here in Puerto Rico. Open Dental doesn't have a way to do this automatically yet, but the recommendation is to create a procedure code called "office visit" and mark "do not usually bill to insurance". Set up a copay fee schedule to include this code and assign a $25 amount for this code on both the regular fee schedule and the copay fee schedule. Make sure you have the copay schedule selected when you set up the patient's insurance. The only problem is you still have to add this procedure code at each visit.
Another way to do this is to add the $25 copay as a comment in the patient's insurance and then you would have the patient pay at each visit, but you would have a negative amount in the account module until the insurance payment arrives.
Jorge Bonilla DMD
Open Dental user since May 2005

ForrestGumpDDS
Posts: 177
Joined: Fri Oct 14, 2011 3:31 pm

Re: PPO with co-pays.

Post by ForrestGumpDDS » Sun Nov 03, 2013 6:41 pm

Thanks Jorge,
The "co-pay" type procedure will not change totals for the other procedures and it shouldn't.
Since there is no way for the system to accomodate it I will do this work around. I will add a pop-up to every patient on the plan for the front desk to collect $25 each visit. Then we will have a neg. balance on that account until the claim is received from the insurance. Then we will figure out where they subtract the $25 from and copy it exactly to the account. Manually...
I wish there was some sort of check-box next to the deductible to adjust the frequency how it is used. Like "at each visit", "once a day" or traditional way.

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