Posterior compostite estimates wrong

[Karrie000]

My treatment plan estimates for posterior composites are not calculating correctly for Delta PPO plans with an alternate benefit. With these plans when the plan allows for an alternate benefit, delta allows me to subtract the amount for the amalgam from my fee schedule not the "contracted" fee for posterior composites. However, OD uses the "contracted allowed" amount for the calculation. For example my fee for post 2 surf comp is $202. the allowed fee with delta is $157. allowed fee for amalgam is $100. If pt has 10% copay the insurance will pay $90, so I would then charge the pt $10(the pt 10% copay) + 202(my fee for comp)-100(allowed fee for amalgam)= $112 .......wheras OD calculates it like this.... $10(the pt 10%copay) + 157(delta allowed fee for comp) - 100(allowed fee for amalg)= $67. So I am giving pt treatment plan estimates saying they owe me $67 when really they owe me $112.

Anyone else having this issue? I put in a feature request but in the mean time I thought about making a whole new delta PPO fee schedule that is identical except for the "allowed amounts" for the posterior composties, which I think would work great. What are other offices doing?

[jordansparks]

I think your suggestion would work.

[savvy]

Forgive me....
Where do you practice ?

[Karrie000]

I practice in Minnesota. And yes, the reimbursement as a PPO Delta provider is not much

[Karrie000]

Thanks Jordan I'll try the separate fee schedule then.

[savvy]

My goodness....
How much is a gallon of regular gas?
A large cup of coffee?
A 3 bedroom/2 bath home?

[atd]

Sorry to get off topic, but...we're in MN as well. Any luck getting a fee schedule from Delta? We're PPO providers but they won't give us a fee schedule stating confidentially reasons, so I have no way to setup the PPO fees in Open Dental. Is that normal in other states? We have to agree the writeoffs but we can't know ahead of time what they are? Every other insurance we contract with is willing to provide a fee schedule.

[savvy]

Greetings,
I'm in California.
For all intends and purposes, Delta Dental of California has three programs:
Delta Dental Premier, which are negotiated fees between Delta and the dentist.
Delta PPO, this is a program whereby dentists agree to accept fees from a fee schedule determined by Delta.
Delta PMI, is a capitation program.

An example of the range in the SF Bay area is as follows:
Dentist fee for a prophy might be $120.00
The negotiated Delta Premier fee might be $107.00
The Delta PPO fee might be $79.
The Delta PMI fee will by free

Delta Premier fees are confidential.
Delta PPO fees are based on a fee schedule that is readily available from Delta Dental.
I hope this helps.

[irfan]

Question- how do you set it up so you can have an alternate code in the first placE? metlife downgrades 2391,2,3 etc to amalgam fees, and i can charge the remaining contracted amount to patient. How is that setup?

I edited the "allowable" fees for metlife but apparently that doesn't change anything for PPO plans?

[jordansparks]

Our "substitution codes" are how we downgrade to amalgams.

[savvy]

I can't seem to find "substitution codes" anywhere in the OD search index.
When I go to a procedure code, ie:D2391, I see that the default is Ins.Subs. Code D2140 Only If Always.
However, when I bill D2391 to insurance companies (some may down grade, some may not) I see nothing in the accounting module that implements the down grade.
How does one know how to turn on this feature on some insurance groups and turn off on others?

[irfan]

I try to change the substitution codes (under "list"-"procedure codes"- then double click a code to bring up its details)...

but this seems to change is across the board for all plans, not just certain ones.

[brentwood]

For plans that you don't want to substitute, you have to click "Don't suvstitute code" checkbox. Please see the manual page below.

http://www.opendental.com/manual/insplan.html

[irfan]

gotcha... seems like i have to go through and hit "dont substitute" for a lot of plans... would be easier if i could force it to substitute instead of the force it to NOT substitute... with the current setup forgetting to check that would mean the patient owes more money, id rather the patient pay too much and get a refund instead of telling them they owe more.

[enamelrod]

next question. I have an insurance that downgrades ceramic crowns to PFM but does not downgrade composites? And another that does just the opposite. how do you set it up?

[jordansparks]

Notes for now. Make sure to get it into the feature requests because every time we overhaul the benefits window, for example, we search through the feature requests to make sure that we're giving users the most current functionality as well as planning for the future. We like to consider all the different insurance benefit nuances at one time. We're clearly heading towards having more boxes in the benefit window and tighter control over things like this on a per-plan basis. What's not so clear to me at the moment is how to manage it for multiple plans at once without having to go into each one. If we just had national plan id numbers, we could share all this info over the internet automatically.