HMO claim affects the patient balance.

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

HMO claim affects the patient balance.

Post by ForrestGumpDDS » Wed Jul 12, 2017 6:03 pm

Hello guys,
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:
If You Need to Bill Insurance (rare)
  1. In the Account module, select the procedure and click New Claim.
    On the Edit Claim window, double click on the procedure.
  2. Change the Fee Billed to Ins amount to the amount the carrier is required to pay.
  3. Change the Insurance Estimate to the same amount.
  4. 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.
Because the claim is for a capitation insurance plan, the amount expected from insurance will not be applied to the patient balance.
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 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):
  1. Exam fee=$70, write off=$70 balance=$0
  2. 1PA fee=$20 write off=$15 balance =$5
I add a patient's payment, $5, now the account balances to $0. Until here, I have now issues.
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:
Payment entry on individual capitation claims is a feature that does not yet exist. In other words, it's a Feature Request.
Am I right?

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cmcgehee
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Re: HMO claim affects the patient balance.

Post by cmcgehee » Thu Jul 13, 2017 8:00 am

Because we don't have the ability to enter payments on capitation claims, the workaround is to mark the plan as a PPO. You can then enter the fee schedule for the carrier as the amount insurance pays plus the patient copay. In your case the fee for the exam would be $30 and the fee for the PA would be $5. See http://opendental.com/manual/planhmosupplemental.html for a longer description.
Chris McGehee
Open Dental Software
http://www.opendental.com

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

Re: HMO claim affects the patient balance.

Post by ForrestGumpDDS » Thu Jul 13, 2017 10:08 am

cmcgehee wrote:Because we don't have the ability to enter payments on capitation claims, the workaround is to mark the plan as a PPO. You can then enter the fee schedule for the carrier as the amount insurance pays plus the patient copay. In your case the fee for the exam would be $30 and the fee for the PA would be $5. See http://opendental.com/manual/planhmosupplemental.html for a longer description.
Thanks,
That's what I have been using in the past. It works, but this solution disallows you to use "track Capitation" report, and makes you create 2 schedules for each plan. So if the Capitation plan pays a supplement on one single procedure, I will have to be creating 2 schedules, which means populating them both and do some math. Takes a lot of time! I just gave up on it 2 years ago, when we stopped taking HMO pts partially because of my inability to delegate this task to the FD person and not worry about missing to collect on those copays and supplemental payments here, there and pretty much everywhere. I want it to be a true HMO setup, one fee schedule, reports available, automations setup, routines described in office manual.
Yesterday, after writing up this post I realized that it does not matter if i cannot apply the payment to the patient account. I can indiscriminately apply them all to the dummy Capitation patient. They will still be on Capitation reports. Maybe I'm overlooking something.

Correct me if I am doing it wrong way, but I am planning to assign that dummy patient a same-name Capitation plan, and will apply monthly capitation checks AND supplements to that insurance as payments. Basically, as per these instructions:
Option 2 (if you must have payments show as insurance payments): Apply as insurance payments so they show on your reports and deposit slips as insurance payments.
a. Add the capitation insurance plan to the dummy patient.
b. Create a dummy procedure with no fee.
c. Create a dummy claim with at least one procedure and 0 fee.
d. Enter the first payment by total.
e. Each time you receive a payment, add the new payment By Total on the same claim (not to the actual patient's claims).
Same negative balance, but now will show on Capitation report in the separate category on Capitation utilization report and voila, I have a full picture of how much I worked, how much written off, how much patients paid, how much the insurance paid.
The only one thing I have a hard time understanding now is this:
Accounts Receivable (A/R) Report: Capitation payments entered under a dummy patient will reflect as credits in the A/R report. This can be avoided by using a billing type that is excluded when running the A/R report.
How do I do this (highlighted part)?

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cmcgehee
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Re: HMO claim affects the patient balance.

Post by cmcgehee » Thu Jul 13, 2017 12:28 pm

That is probably the best workaround if you want the P&I and Track Capitation Reports to be accurate.
ForrestGumpDDS wrote:Accounts Receivable (A/R) Report: Capitation payments entered under a dummy patient will reflect as credits in the A/R report. This can be avoided by using a billing type that is excluded when running the A/R report.
To do this, create a new billing type called something like "Capitation Carrier Payments" and set that as the billing type on your dummy carrier patient. Then whenever you run the A/R Aging report, unselect the "Capitation Carrier Payments" billing type.
Chris McGehee
Open Dental Software
http://www.opendental.com

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

Re: HMO claim affects the patient balance.

Post by ForrestGumpDDS » Thu Jul 13, 2017 4:30 pm

cmcgehee wrote: To do this, create a new billing type called something like "Capitation Carrier Payments" and set that as the billing type on your dummy carrier patient. Then whenever you run the A/R Aging report, unselect the "Capitation Carrier Payments" billing type.
Just did it! Excellent! My office manager is all set.
I also created an N-code (no fee procedure) with the similar name. Created 7 completed procedures to match the number and amounts of checks (changed the dates for each one so they sit next to the respective check). Not sure how to attach the existing payments to them, but she should be able to figure it out.

One last thing. I did not read carefully the instructions and created a new payment type, not a billing type. I notice that there's no option of deleting it. Is it a wise idea to find the related rows in the database and wipe it from there? I have not used the new "payment type" anywhere. As soon as i realized my mistake, I created a new "billing type" and would like to get rid of the payment type entry instead of using "hide it" if I can.

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cmcgehee
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Re: HMO claim affects the patient balance.

Post by cmcgehee » Mon Jul 17, 2017 8:11 am

Our position is that it is never wise to wipe out data from a live database. I would recommend hiding it and adding "DO NOT USE" to the name. The only people who are ever going to see this are the ones with the Setup security permission anyways.
Chris McGehee
Open Dental Software
http://www.opendental.com

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

Re: HMO claim affects the patient balance.

Post by ForrestGumpDDS » Thu Jul 20, 2017 5:22 pm

ok :|
One last question. I checked w. OM about attaching the checks with the payments from Capitation InsCo's to the dummy procedure. She says she is having problems to attach the payment and using "Finalize payment" button.
She creates the claim to Capitation, edits the amounts as recommended, clicks OK. Opens the claim again, changes the status to Received, then "Add by total", enters the amount (we tried as well "Enter by procedure", same result).
Then she clicks "Finalize the payment" and sees "There are no valid payments received for this claim" warning. Then exits.

What are we doing wrong?

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cmcgehee
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Re: HMO claim affects the patient balance.

Post by cmcgehee » Mon Jul 24, 2017 8:16 am

As long as you have Claim Procedure with a status of Received or Supplemental, it should allow you to click Finalize Payment. Are you changing the status on the Claim Procedure to a different status like CapComplete?
Chris McGehee
Open Dental Software
http://www.opendental.com

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

Re: HMO claim affects the patient balance.

Post by ForrestGumpDDS » Tue Aug 01, 2017 2:43 pm

cmcgehee wrote:As long as you have Claim Procedure with a status of Received or Supplemental, it should allow you to click Finalize Payment. Are you changing the status on the Claim Procedure to a different status like CapComplete?
No, I'm not.
This is what I do.
  1. the (dummy) pt. has an insurance set to that inisurance, type capitation. Company=Dominion, Schedule=none, Copay schedule=Dominion DHMO, type=capitation, subscriber ID - random
  2. I received a check from the insurance for capitation payment, let's say $160. The check has been introduced as a regular check payment (which is probably not a correct way, but keep reading. This is money and must be entered into the system for now at least somehow by the manager)
  3. I create a N9988 procedure (the code had been previously created) set it complete, double-click on the procedure, assign manually $160 fee.
    Image
    The account balance is still 0 (the check is the same amount as the procedure fee, the claim has no payments posted yet)
    Image
    In the estimates section of the window I see an entry, with the status CapComplete.
    Image
    I close the window.
  4. In the Account module I highlight the procedure and create the claim. Edit the estimated amounts to $160 as per instructions, mark the claim "Received" and close the claim window.
  5. Open the claim window again. In the Procedures area I see one entry, it has a status "CapClaim", while the claim status is "Received".
    Image
    Click "Finalize" (before or after editing the amounts by Total or by Procedure). By the way, entering the amounts by "Supplemental" is not permitted, the error says: "All selected procedures must be status received"
    Image.
  6. Clicking on "Finalize" brings me the error "There are no valid received payments for this claim".
    Image
  7. The balance is now -$106
    Image
I hope it all makes sense.

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cmcgehee
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Re: HMO claim affects the patient balance.

Post by cmcgehee » Tue Aug 01, 2017 5:42 pm

Here are a few things that differ from our recommended workflow:
1) It's best to enter the N9988 procedure with a $0 fee. If you put in a non-zero amount, it will skew your production numbers in an undesirable way.
2) You should enter the payment as a patient payment or an insurance payment, but not both. If you decide to enter it as a patient payment, then you can sidestep having to create a claim and enter the payment there.
3) When you enter the payment on the claim window, if you enter the payment by clicking "As Total", then you will be permitted to click "Finalize Payment".
Chris McGehee
Open Dental Software
http://www.opendental.com

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

Re: HMO claim affects the patient balance.

Post by ForrestGumpDDS » Thu Aug 03, 2017 1:41 pm

>>>You should enter the payment as a patient payment or an insurance payment, but not both. If you decide to enter it as a patient payment, then you can sidestep having to create a claim and enter the payment there.
I totally agree.
The reason you see it on the screenshots is because I had to find out the working way to attach the payment as an insurance check, and only after that to delete the payment made as a "patient payment".
Anyway, using "As total" when applying the payment did the trick. Thank you.
This was what I was trying to achieve. Now I can see ALL of the payments made by patient and capitation checks in one report that will be accurate to the last dollar. Cool! 8)

I was trying to delete the checks posted as a "patient checks" in the past to replace them with above described procedure and noticed that they are not removable any longer since they got attached to deposit slips. Please confirm that I am correct and those checks will stay and will not be able to be deleted once the deposit was created.

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cmcgehee
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Location: Salem, Oregon

Re: HMO claim affects the patient balance.

Post by cmcgehee » Thu Aug 03, 2017 3:24 pm

As long as those patient payments are attached to deposits, you will not be able to delete them. You can delete the deposit and recreate it without attaching the patient payment. Then you will be allowed to delete the payment.
Chris McGehee
Open Dental Software
http://www.opendental.com

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