Types of Insurance Plans 

In the Insurance Plan edit window, there is a Plan Type selection at the lower left.  The options for plan types are as follows:

Category Percentage
This is used for traditional percentage insurance plans.  Use this type if you are NOT contractually obligated to reduce your fees. In other words if you are not a PPO Provider.

This can also be used for PPO plans if you do not wish to track writeoffs.  It can be a simpler approach than the PPO Percentage type discussed below.  Set the Insurance Plan fee schedule to be the fee schedule for the PPO.  The fee for each procedure will then be the PPO fee instead of the standard office fee.  One disadvantage of doing it this way is that the patients will not be able to see the standard office fees, and they may not be aware that a discount is being given.  In order for standard office fees to show on the insurance claim, check the box for "claims show UCR fee..." It is always recommende to bill insurance compa nies with the UCR fees for the practice.

Advanced usage 'allowed': An allowed Fee Schedule can be used to get more accurate estimates. If you know the UCR fees for a plan but you are not contractually obligated to follow them, then you can use the allowed fee schedule in addition to the regular fee schedule for the plan. Set up a new 'allowed' fee schedule with the UCR fees for that insurance plan.  In the Insurance Plan edit window, set the main Fee Schedule to your standard fee schedule and set the Carrier Allowed Amounts to your newly created fee schedule.  All fees will then show as your standard fees, but when calculating estimates, the allowed amount will be used in the ClaimProcs window.   Percentages will be based on the allowed fee schedule. If the published fee schedule is showing exact amounts that will be paid, then set percentages for all categories to 100%. When using an allowed fee schedule, the patient will still be responsible for any extra amount that your office charges above the published fees. This process can be automated using the Blue Book feature.

Advanced usage 'co-pay': Not typically used for this type of insurance plan.

PPO Percentage
Preferred Provider Organizations.  Use this type only if you ARE contractually obligated to reduce your fees.   Because you are enrolled with the insurance company, you will have access to a published list of allowed fees.  You are not allowed to charge the patient more than the published fees.  The insurance portion is calculated as a percentage of the published fee schedule and the patient pays the rest, up to the amount of the published fee schedule.  Set the fee schedule for the insurance plan to the fee schedule provided by the carrier.  This will be the fee that the estimates are based on, the fee allowed by the carrier. But the fee that shows for the procedure will be the standard fee for your office.  The difference will go in as an automatic writeoff.

The standard fee for a PPO plan is pulled from the fee schedule for the provider assigned to the patient. If the standard fee for the provider is lower than the PPO fee, then the PPO fee will be used.   When using a PPO plan type, you don't have to worry about checking the box for "claims show UCR fee..." because they will already be showing your UCR fee.

See Reports Setup for information on the Default to using Proc Date for PPO writeoffs option.  This is important if you are using a Lock Date in Security.

Advanced usage "allowed": Not used for this type of insurance plan. Setting an allowed fee schedule will have no effect, because the PPO mechanism is already internally making use of allowed fees.

Advanced usage "co-pay": If you also have a copay amount that the patient is to pay for each procedure, then you may set up a co-pay fee schedule. In this case you will generally set all the percentages to 100% so that everything above the co-pay amount will be calculated as the insurance portion.  Percentage calculations will still be performed on the remaining amounts if they are not set to 100%.  If you only have the insurance co-pay fee schedule available rather than the patient co-pay amounts, then you will have to subtract to obtain each fee in the co-pay fee schedule.

There is an option in Family Module Setup to let you select how blank co-pay entries are handled.  They can either be handled as if they were zeros, or the patient can be responsible for the remainder when a blank co-pay amount is encountered.

Medicaid
When setting up the Insurance Plan, set the Plan Type to flat co-pay. This disables all the percentages and establishes 100% coverage. Then, check the box for 'Claims show UCR'. If it applies, check the alternate code box. The alternate code for each ADA code can be specified in the Procedure Code Setup window. Then, when you send your claim, it will show the alternate codes and your UCR fees. Insurance estimates will not take into account any percentages, maximums, or deductibles. Set the Fee Schedule for the Insurance Plan to the Medicaid fee schedule. If insurance does not cover a procedure for some reason, you will write it off in the Edit Claim window when the insurance payment comes in.

Per-visit patient co-pays are covered on the Benefit Info page.

If you wish to track your Medicaid writeoffs, then set up the insplan as a PPO type.  The Medicaid type described here does not generate trackable writeoffs.

Advanced usage "allowed": Not used for this type of insurance plan.

Advanced usage "co-pay": If you also have copay amounts that the patient is to pay for some procedures, then you may set up a co-pay fee schedule.  This copay fee schedule can have just a few fees on it, with the rest blank.  If you only have the insurance co-pay fee schedule available rather than the patient co-pay amounts, then you will have to subtract to obtain each fee in the co-pay fee schedule.

Capitation
This feature must be turned on in the Show Features window for this plan type to show as an option.
Also known as HMO or DMO, capitation pays a flat fee every month to the office regardless of what work is done on the patients. Patients pay a flat fee for some procedures and no fee for other procedures. Sometimes, a fee for the lab portion of certain procedures can be billed to insurance. Set the insurance plan type to Capitation and assign your standard fee schedule. These fees will be displayed in the treatment plan and in the account, but they will not affect the patient's balance after they are complete. For any patient portions, set up the co-pay fee schedule with the amount that the patient is required to pay for each procedure.

In the rare case that you need to bill insurance, select the procedure from the Account module and then click the Ins Claim button. Before sending the claim, change the fee billed to the amount that the carrier is required to pay. Change the estimate to the same amount, then send the claim. Because the claim is for a capitation insurance plan, the amount expected from insurance will not be applied to the patient balance.

This section is very technical:
Internally, a capitation claim creates a second ClaimProc.  One claimproc has a status of CapComplete and contains the writeoff for the procedure.  The second claimproc has a status of CapClaim and is only used to show the procedure detail for the claim.  The CapClaim claimproc will not change to any other status when the claim is later received.  At some point in the past, it might have been possible to enter the amount paid upon receipt of the insurance payment.  But that feature is definitely not functional in the current version. It is possible that the feature was lost when the Account module was overhauled in version 5.6.  It would take some research to be certain.  We are reluctant to call it a bug because adding it back would be complex and could cause other bugs.  If there is any office that has historical payment data before version 5.6 and feels that the behavior has changed, please contact us.  Otherwise, we will treat payment entry as a feature that does not yet exist.  In other words, it's a feature request.

When the claim comes back, do not enter the payment within the claim.  You could enter a note describing the payment if you wish.  The payment itself will be recorded in the dummy patient for the carrier as explained below.

To enter the monthly payments as they come in from the carrier, create a dummy patient with the same name as the carrier. Apply all payments to that patient as patient checks. That way, they will show on your deposit slips. Functionality will later be added for better handling of capitation payments.

The utilization report can be run at the end of each month from the Main Menu under Reports, showing a list of all procedures performed for capitation along with the UCR fee and the patient co-pay.

Advanced usage "co-pay": If you have a copay amount that the patient is to pay for each procedure, then you may set up an copay fee schedule. This copay fee schedule can have just a few fees on it, with the rest blank.  The copay amount would be used in the ClaimProc window.

Other Situations

HMOs with supplemental payments and copays (very common in Texas)
These must be entered as Type PPO. Set benefits to 100% for all categories. Create a 'Copay' fee schedule with patient copays. Also create a 'Normal' fee schedule with insurance supplemental amounts + patient copay for each procedure. Make sure to put 0 if there is no fee, or else the patient will get charged the UCR fee. This might be the case for something like an electric toothbrush.

If you have entered this as Capitation with a Copay fee schedule, you can fix it by following these steps:

1. Go to Lists>Procedure Codes and click the 'Fee Scheds' Button. Add a 'Normal' type fee schedule with a similar but not identical name to the existing 'Copay' tyep fee schedule.

2. Put the fees = to the Copay fee+ supplemental fee for each procedure into the new 'Normal' Fee schedule. Make sure to enter 0 for all fees where there is no supplemental fee nor a copay.

3. Open each corresponding plan, switch fee schedule to the new 'Normal' Fee schedule, change plan type to PPO % from capitation.

4. Set benefits to 100% for all benefit categories.

PPOs with fee schedules that change after first year
These can be easily handled by using two insurance plans: one for preventive services, and one for basic services. These will need to be updated manually after the first year so that estimates etc. are monitored closely during the transition to the second year, when benefits will have to be updated in Open Dental.