Accurate Payment Estimates with MAC minus Fee Schedule plans
Accurate Payment Estimates with MAC minus Fee Schedule plans
Could someone tell me the proper way to set up insurance in the patient chart for a situation where there is a Maximum Allowable Charge (MAC) and the reimbursement is far lower, with the patient being responsible for the difference? I'm not sure how to properly set this up in the Insurance Plan window i.e., PPO percentage, Fee Schedule, Other Fee Schedule etc... Thanks in advance, Anne
Re: Accurate Payment Estimates with MAC minus Fee Schedule p
Hi Anne,
These plans are becoming more and more common, unfortunately. The Max Allowed Charge will be the fee schedule you use to calculate your writeoffs. That should be assigned to the plan as a regular PPO fee schedule.
The difference between the MAC and the reimbursement rate is the patient's responsibility, and can be added as a Copay Fee Schedule to the same plan. http://opendental.com/manual/planppo.html
For example, say your fee is $100 for a procedure. The MAC is $80, however the reimbursement rate is only $50.
In the insurance plan you would set the plan type to PPO Percentage. The assigned MAC fee schedule would contain the $80. You would also attach a copay fee scheule and the fee would be the difference between the two rates ($80 - $50 = $30).
Open Dental uses the following calculations to determine insurance payments.
1. Office Fee - PPO Fee (Normal Fee Schedule) = Write off
2. (PPO Fee - Deductible - Patient Copay) x Coverage Percentage = Insurance Payment ***This differs a little for downgrades. The PPO Fee would be the downgrade procedure PPO Fee.
3. Office Fee - Writeoff - Insurance Payment = Patient Portion.
So, in the example cited:
1. $100 - $80 = $20
2. ($80 - $30) x 100% = $50
3. $100 - $20 - $50 = $30
These plans are becoming more and more common, unfortunately. The Max Allowed Charge will be the fee schedule you use to calculate your writeoffs. That should be assigned to the plan as a regular PPO fee schedule.
The difference between the MAC and the reimbursement rate is the patient's responsibility, and can be added as a Copay Fee Schedule to the same plan. http://opendental.com/manual/planppo.html
For example, say your fee is $100 for a procedure. The MAC is $80, however the reimbursement rate is only $50.
In the insurance plan you would set the plan type to PPO Percentage. The assigned MAC fee schedule would contain the $80. You would also attach a copay fee scheule and the fee would be the difference between the two rates ($80 - $50 = $30).
Open Dental uses the following calculations to determine insurance payments.
1. Office Fee - PPO Fee (Normal Fee Schedule) = Write off
2. (PPO Fee - Deductible - Patient Copay) x Coverage Percentage = Insurance Payment ***This differs a little for downgrades. The PPO Fee would be the downgrade procedure PPO Fee.
3. Office Fee - Writeoff - Insurance Payment = Patient Portion.
So, in the example cited:
1. $100 - $80 = $20
2. ($80 - $30) x 100% = $50
3. $100 - $20 - $50 = $30
Entropy isn't what it used to be...
Arna Meyer
Arna Meyer
Re: Accurate Payment Estimates with MAC minus Fee Schedule p
Thank you very much! I didn't realize it was that simple. Your explanation was perfect. Many thanks.
Re: Accurate Payment Estimates with MAC minus Fee Schedule p
Arna,
Could you tell me how I might have mistakenly set up the above described scenario? I've entered the fee schedule and attached it to the plan (PPO percentage, fee schedule attached). Under the 'other fee schedule' field, I've attached the copay fee schedule. When the estimates are coming up (during claim entry), the fields are empty for insurance estimates but the write offs are accurate. I must've done something incorrectly- any idea what that might be? Thanks in advance! Anne
Could you tell me how I might have mistakenly set up the above described scenario? I've entered the fee schedule and attached it to the plan (PPO percentage, fee schedule attached). Under the 'other fee schedule' field, I've attached the copay fee schedule. When the estimates are coming up (during claim entry), the fields are empty for insurance estimates but the write offs are accurate. I must've done something incorrectly- any idea what that might be? Thanks in advance! Anne
Re: Accurate Payment Estimates with MAC minus Fee Schedule p
I do this for Delta PPO. I signed up for Delta Premier, but Delta will pay only the PPO fee and the patient is responsible for the difference up to the Premier fee. The way I set that up is I made a Premier fee schedule and a Delta allowed fee schedule (PPO fees). I set plan type to Category percentage. OD calculates the difference between both and the patient is responsible for it.
Jorge Bonilla DMD
Open Dental user since May 2005
Open Dental user since May 2005
Re: Accurate Payment Estimates with MAC minus Fee Schedule p
Thank you! Forgive my very basic questions. So, you have play type set as Category percentage. Fee schedule (just below this field) set to the appropriate fee schedule. Under "other fee schedules" you have the co-pay amounts listed? Do you have anything listed with carrier allowed amounts? When I select this field the option is defaulted to 'none' and so I'm not sure if this field is set up correctly? I had the plan type set as PPO percentage because we participate. So, this may not have been correct then? Thanks in advance for your help.
Re: Accurate Payment Estimates with MAC minus Fee Schedule p
I have it as Category percentage because I'm not a Delta PPO provider, I'm a Delta Premier provider. Anyway, I think the only way that allowed fee schedules will work is with Category percentage plans. I have a normal fee schedule called Delta Premier which has my contracted Premier fees. I also have an "Out of Network" fee schedule with the allowed PPO fees. depending on the version of Open Dental that you have, this type of fee schedule is either called an "Allowed" fee schedule or an "Out of Network" fee schedule. When you enter a fee schedule into Open Dental, you define it as "Normal", "Co-pay", or "Out of Network (Allowed)". Once you do that, enter Category percentage as plan type in the definition window. Under that, enter Delta Premier as the Normal fee schedule. Under that is the copay and allowed fee schedule fields. Select the Delta PPO allowed fee schedule in the "Carrier allowed amounts" slot.
Jorge Bonilla DMD
Open Dental user since May 2005
Open Dental user since May 2005
Re: Accurate Payment Estimates with MAC minus Fee Schedule p
Great. Thank you so very much for taking the time to respond - very helpful and much appreciated.