Could you please clarify something for me?
I am setting up an HMO plan and trying to check it if the claim for supplemental payment will work properly. Following this instructions: http://www.opendental.com/manual/plancapitation.html
Precisely, this particular part of it:
So, I expect to collect from the insurance 30 dollars on a bundle of 3 procedures. Hence the claim needs to be created and sent. For simplicity sake, let's say it would be one procedure, not 3.If You Need to Bill Insurance (rare)Because the claim is for a capitation insurance plan, the amount expected from insurance will not be applied to the patient balance.
- In the Account module, select the procedure and click New Claim.
On the Edit Claim window, double click on the procedure.- Change the Fee Billed to Ins amount to the amount the carrier is required to pay.
- Change the Insurance Estimate to the same amount.
- Click OK, then send the claim. If you do not expect to apply a payment for the claim, we recommend marking the claim as 'received' so it doesn't show on the Outstanding Insurance Claims report.
If I try to enter payment it in the Claim Edit window, I get the amount entered written off of the patient's copay amount which without that claim would not be affected.
Example:
The patient has an exam, 1PA and a filling done. My fees are $70 for exam and $20 for PA. The HMO is supposed to pay $30 for the exam and nothing else.
The patient's copay schedule says $0 for exam, $5 for PA for the x-ray.
The pt. ins setup to Capitation, no downgrades, no "normal" fee schedule attached, and a co-pay fee schedule attached with $0 for the exam and $5 for PA x-ray.
When I complete the appointment, the patient's balance shows as $5 and breaks down as follows (without creating any claims):
- Exam fee=$70, write off=$70 balance=$0
- 1PA fee=$20 write off=$15 balance =$5
Then I follow the above mentioned instructions to create the claim.
When I create the claim for the Exam, I change "fee billed" and "insurance estimate" to $30 as per instructions. Click OK. The patient balance is still $0, insurance estimate is $0 as well, despite all altered "ins estimate" related fields.
I open the claim and enter the $30 of insurance payment, click OK and now the patient has negative $30 balance, ins estimate - 0.
Is this a normal behavior? I further read on the article and suspect that this is:
Am I right?Payment entry on individual capitation claims is a feature that does not yet exist. In other words, it's a Feature Request.