Open Dental is not sending the proper fee to insurance

[Mgostigian]

I've been trying to deal with this issue for months and am getting tired of it.

Why does Open Dental keep sending our office fee to the insurance company when we have the insurance fee schedule selected from the drop down, and the checkbox "Claims show UCR fee, not billed fee" is NOT checked. I would think that this checkbox would send to insurance companies the PPO fee, not our UCR fee. Is this a glitch or is there only one option of sending UCR fee?

We've been on the phone with OD support and they pointed us to the same page from the manual we've gone over a dozen times with no resolution. All I want to do is submit the insurance fee, NOT UCR fee.

[Arna]

Is the right fee posting to the Account Module?
Why are you reducing your fees for claim submission? Are you absolutely sure your fee schedules are correct? If not, you could be cutting yourself short on reimbursements.

[Mgostigian]

No, it is not showing up properly in the accounts module. It is showing up as our UCR despite the correct checkbox NOT being checked as I stated above. It shows that the patient owes us our UCR fees even though the correct insurance fee schedule is attached. I am reducing my fee for claim submission because that is the way I want to do it.

[Arna]

It's designed that way. Your plan type is PPO Percentage, which bills your full fee and calculates writeoffs in your claims.
If you change your plan type to Category Percentage, Open Dental will replace your full fee with the assigned fee schedule in the plan: http://opendental.com/manual/planppo.html (second section).
I am all for you going this route, as long as you are aware that the fees could be wrong (they rely on your fee schedules assigned to be correct). I would recommend still submitting full fee to insurance, but not having it post to the account. That way, you can adjust the billed fee to the account if insurance decides they want to pay more than anticipated .

[Mgostigian]

What if switching to Category Percentage STILL results in the office fee being sent, not the insurance fee?

[Arna]

That is what the check box in the plan is for. You can choose to submit your Office Fee or the Billed Fee (Insurance Fee).

[Mgostigian]

What do I do if it is NOT checked and it still submits as the UCR fee?

[Arna]

You need to manually change the fees if the procedures are already set complete. Moving forward, the plan will use the Insurance Fee to Treatment Plan, but Open Dental does not retroactively change completed procedure fees with a fee schedule or plan change.

[Mgostigian]

I am not sure if I'm explaining this correctly.

This is the insurance breakdown. As you can see, Assurant fee schedule is selected. Category percentage is selected. Claims show UCR fee, not billed fee is NOT selected:



We enter treatment plan and this is what it gives us:



It is showing my office fees, seen here:



Not the Assurant fees, seen here:


What are we missing here?

[dgraffeo]

I've set up test cases using the same settings you are and I cannot reproduce the issue; it pulls from the correct fee schedule for me. Arna may have more ideas but it may be a good idea to call in and let us grab a copy of your database so we can see why it's pulling from the wrong fee schedule and we can give you a definitive answer. Additionally, based on your screenshots it looks like you may be using a fairly old version of OpenDental. I can't find a bugfix for your specific problem but it may be worth your time to update and see if it fixes the issue for you, not to mention have numerous other bug fixes.

[Arna]

Was this work treatment planned AFTER you made the changes to the plan?
As I mentioned before, if the work was Tx planned before the change, you'll need to adjust manually. Try charting another procedure, and it should pull the Assurant/DHA fees for you now.

[gthiele]

FWIW, here's what Charles Blair DDS, a noted authority on fees, codes, and insurance has to say about the advantages of submitting full fee:

1 Proper calculation of patient benefits for coordination of benefits by secondary insurance (your full fee can often be obtained from the combination of two low-fee PPO plans!)

2 PPO carriers use submitted fees to determine fee increases; by submitting your full fee you'll ensure you receive the greater benefit if the PPO raises its fee schedule

3 UCR is set by insurance companies based upon fee submitted data, not contracted fees

4 Submitting full-fees with help you accurately track insurance write-offs for evaluation of various PPO contracts

[Mgostigian]

Was this work treatment planned AFTER you made the changes to the plan?
As I mentioned before, if the work was Tx planned before the change, you'll need to adjust manually. Try charting another procedure, and it should pull the Assurant/DHA fees for you now.

I am actually not sure if it was. I do know we've definitely had this issue AFTER everything was entered in. For example, all the insurance info is entered as seen above and we tx plan a crown and buildup, it will still tx plan the crown at our UCR fees, not the insurance fee.

[Mgostigian]

I've set up test cases using the same settings you are and I cannot reproduce the issue; it pulls from the correct fee schedule for me. Arna may have more ideas but it may be a good idea to call in and let us grab a copy of your database so we can see why it's pulling from the wrong fee schedule and we can give you a definitive answer. Additionally, based on your screenshots it looks like you may be using a fairly old version of OpenDental. I can't find a bugfix for your specific problem but it may be worth your time to update and see if it fixes the issue for you, not to mention have numerous other bug fixes.

Thank you, I will look into updating the software.

[Arna]

You should give us a call to demonstrate when you have a moment. Something is getting lost in translation via text.