Treatment Plan Estimates with Two In-Network PPOs, but the Secondary has a higher allowable

[ericpalmerdds]

We are struggling to give accurate estimates for patients with two PPO insurances that we are in network with. We have a wide range of PPO allowables in our practice, as you'll see in the example below. First off, our COB Rule is set to Standard. And we are using PPO Percentage Plan Type with the associated fee schedule. I've tried fiddling around with different COB Rule options like Basic and Carve Out, and different Plan Type options like Category Percentage and PPO Fixed Benefit, but I have not found a combination that works. I thought I almost had it when using the PPO Fixed Benefit Plan Type, but that only lets me have all benefit categories at 100% coverage, and when I changed something to 80% or 50% it reverted back to PPO Percentage on its own.

In our office, D2740 full fee is $1,338.

The primary has an allowable of $592. The estimated coverage percentage for this is 50%. The treatment plan estimates that Pri Ins will pay $296. When you double click this code and open the "Procedure Info" window, it shows an estimated write off of $746 on the line of this primary insurance.

The Secondary has an allowable of $1,177. The estimated coverage percentage for this is 50%. The treatment plan estimates that the Sec Ins will pay $296. When you open that same "Procedure Info" window, it shows $0 write off from the Secondary insurance.

In the treatment plan module in the column for estimated Patient portion, it says $0.

The estimated patient portion of $0 and write off are my main problems. I would like to estimate the worst case scenario. I know different plans in actuality with carry out coordination of benefits differently when claims are processed. But in this specific scenario I want Open Dental treatment plan module to estimate the write off from the higher allowable, not the primary allowable. So in this case, I would want it to estimate a write off of $161 (full fee minus higher allowable). In the opposite scenario where the primary has the higher allowable, Open Dental seems to do this fine. But I want it to estimate the write off from the higher allowable, not the primary allowable.

I know I can manually change this to make it estimate how I want, and thus get the estimate I want. Open Dental is smart enough where if I just double click the code in the tx plan module, open the Procedure Info window, then double click the top line with the primary insurance in the "Insurance Estimates and Payments" section, it the opens the "Edit Claim Procedure" window and I can change the Write-off Estimate from $746 to $0. Then hit save. Then Open Dental will take away that primary write off from the Insurance Estimates and Payments section, and then put in the Secondary write off of $161 on its own. And now it does estimate an estimated Sec Ins payment of $588.50, and more importantly estimates a patient portion of $292.50. However, it's not really reasonable for my staff to know when and to spend time to go in these windows and zero out estimated primary write offs.

Essentially, I am asking if I can tell Open Dental to use the higher allowable when estimating two in-network PPO plan benefits, whether or not that higher allowable is from the primary plan or the secondary plan (or even a tertiary plan).

Sorry for the long essay, thanks in advance for any help!

[rhaber123]

Enter the primary insurance as out of network, and Open dental will bill your UCR fees, no write off.
Enter the secondary as in network , and open dental will use this company fee schedule for the write off

[ericpalmerdds]

By enter the primary insurance as out of network, do you mean put the plan type as Category Percentage? Or do you mean with Plan Type PPO Percentage but Standard Fee Schedule (rather than the PPOs fee schedule)?