Each fee schedule type is very specific regarding its function in Denticon.
NOTE: If a fee schedule is not entered with the correct type, the type can not be changed. Likewise, the amounts cannot be copied to another schedule of a different type. Rather, the fee schedule amounts must be re-entered with the correct type.
Office fees are usually referred to as “Office Default” or “Office UCR” fees. These fees are charged to patients who do not have insurance. They are also the fees charged to insurance carriers if the office is not a preferred provider through either a carrier’s PPO program or through a Managed Care program. Patient discount plan fee schedules are entered as Office type when there can be no insurance claim made to the schedule sponsor for financial reimbursement. There can be several office fee schedules – staff, xx% professional discount, xx% Senior discount.
Insurance – PPO fee schedules include fees that a provider is required to charge according to a signed agreement with the insurance carrier. The PPO amount is the maximum allowable amount from which a patient’s insurance reimbursement is paid according to percentage(s) allowed according to the plan’s policy documents. Because a provider must charge the same fees for all plans from the specified carrier, PPO fee schedules are attached to carriers.
Insurance – Managed Care fee schedules indicate fees that a provider is required to charge according to a signed agreement with the insurance carrier. They also include the amount payable by the patient (i.e., co-pay) and insurance carrier supplemental fees owed the office. Because each plan is associated to a unique fee schedule, the Managed Care fee schedules are attached to specific managed care plans.
Insurance – Smart Fees can be used if the office is not a preferred provider, therefore is able to charge the office’s UCR schedule on insurance claims. The amounts are known when the carrier indicates on an EOB exactly all it will pay for a particular procedure. It does not consider percentages covered according to the insurance plan setup. It is plan specific and is built over time when the user inputs insurance reimbursement payments to a patient insurance claim and chooses to utilize the Smart Fee function of Denticon. The amount is the static, always paid amount from the insurance carrier if the provider office is not a member of the carrier’s PPO network. The amount in the smart fee is updated upon the last posted payment information posted in the smart fee column of an insurance payment. The patient will be charged the difference between the amount entered in the insurance column and the UCR. Because the smart fees are unique to understanding the allowable payable amounts for a particular plan, smart fee schedules are attached to specific plans. Note: Smart fees are generally disabled upon starting Denticon. The smart fee function can be turned on per written request to support@planetdds.com.
Insurance – Patient Co-Pay schedules are similar to Smart Fees. They are opposite due to the fact that these fees are used to indicate the amount of the patient's estimate portion. Similar to Smart Fees, this type schedule must to be attached to the insurance plan. It does not consider percentages covered according to the insurance plan setup. It is plan specific. The amount is the static, always paid amount from the patient. Because the patient co-pay amounts are unique to understanding the patient-receivable amounts for a particular plan, patient co-pay schedules are attached to specific plans.
If there is not a fee schedule attached to the carrier, the system will calculate the amount of the insurance reimbursement based on office default fee schedule. If there is a fee schedule attached to the carrier (example: PPO schedule), the system will calculate the insurance portion to be the difference between the amount indicated in the “Patient Co-Pay” schedule and the PPO schedule.
Difference between the “Patient Co-Pay” and the “Smart Fee” schedules:
o Smart fee indicates what the insurance will pay.
o Patient Co-Pay indicates only what the patient pays.
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SCHEDULE TYPE |
WHEN and HOW USED |
|
Office |
The patient’s default schedule Attached to patients who do not have dental insurance (cash patients) Attached to patients who do have dental insurance; represents the charge for procedures not found in the PPO or Managed Care schedules |
|
Insurance – PPO |
Used when the office is a contracted provider with the carrier Attached to the indemnity carrier (example: MetLife, Delta Dental, Guardian) |
|
Insurance – Managed Care |
Used when the office is a contracted provider with the plan Attached to a Managed Care plan (example: DMO, DHMO, Capitation, Medicaid) |
|
Insurance – Smart Fees |
Used when the office is not a contracted provider with the carrier Indicates the amount of insurance reimbursement Attached to the plan |
|
Insurance – Patient Co-Pay |
Used when the office is not a contracted provider with the carrier Indicates only what the patient pays Attached to the plan |