Open Dental Forum

We recently went out of network with United Concordia. Since we were previously in network we do have access to their allowable amounts which is beneficial. We are having a hard time getting accurate estimates in the Open Dental treatment plan area. Per our EOBs the patient portion should be our UCR fee minus what insurance paid (which is the indicated % of their allowable amounts). Our treatment plans are reflecting insurance paying the % of our fees instead and the patient portion is now off by 100s of dollars.

EX: Coverage at 80%
This is what is populating
UCR: $296.00 Ins: $236.80 Pt: $59.20
Allowable: $115.38
This is what it should be per the EOB
UCR: $296.00 Ins: $92.31 Pt: $203.69

The only thing that has semi worked to get us closer to an accurate estimate with treatment is by using the co-insurance amount as our % in the insurance information area. IE: where we would typically put that the plan will pay 80% for restorative if we change it to 20%. By doing so our estimates are MUCH closer. Is this the best way to proceed? Or is there another way?

What you are doing is the easiest solution.

When we get an out of Network patients, my receptionist will call the insurance and try to see how much the insurance will pay for the prophy, Exam , and a one surface filling.
Most of the times she can get that information from the insurance representative.

In general, our office fees are mostly higher than the UCR fees in our area.
After she receive the estimated fees that the insurance will pay for the above procedures, she will need to pick a percentage that will be close to our fees.


It will be an estimated percentage.



Let's say your prophy fee is $100.
My receptionist will call and ask how much they will pay for the cleaning, most insurance customer service rep will let you know how much they will pay,

they may not tell you about the crown fee, or root canal fee, but most of them will tell you about the prophy fee. And if the first one will not tell you, call a second time, or a second day, and the second rep will most likely tell you about the prophy and exam fees.

1- So if the answer is $ 82, we pick the 85% fee schedule as the insurance "allowed amount"
2- if the answer is $58, we pick the 50% fee schedule as the insurance " carrier allowed amount"
etc....

Again, this is an ESTIMATE, but you will be able to have a better estimated treatment plan, mainly if the ins fees are in the 25% or less. Very low "allowed amount"


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But to be more accurate, and if you have that fee schedule, you can use the " Carrier allowed amount " option in the insurance page.

Carrier Allowed




Contact OD support if you want to learn how to use the "Carrier ALlowed " amount, or how to use OD Blue book