Traditional Percentage Insurance
Set the Plan Type to Category Percentage. You do still have the option to specify
a co-pay fee schedule, even though the plan type is not flat co-pay. You would
only do this if it is an insurance company you use a lot and you happen to know
exactly what they will cover for certain procedures. Any amounts that you enter
into the co-pay fee schedule will override the percentages that you set up by
category. A co-pay fee of zero will not override the category percentage. If
you don't want to override the percentages, then leave the co-pay fee schedule
selection blank when setting up that insurance plan. You probably wouldn't want
to set up a separate fee schedule for other carriers because then you would
not be billing the patient the full amount.
PPO
Very similar to traditional. They also cover based on percentage by category.
Some plans will cover 100% and allow a flat fee be charged to the patient for
certain procedures. If you are enrolled in a PPO, enter their fees in a separate
fee schedule. If you are not enrolled, then use your standard fee schedule,
and just understand that they might not pay as much as if you were enrolled
if your fees are higher than their UCR fees. If the insurance has a flat fee
charge for certain procedures, set up a co-pay fee schedule with those co-pay
amounts. They will override the standard fee schedule percentages.
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 boxes for 'write off' and 'use 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. The annual
max box as well as the deductible box should be blank. 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. If insurance
does not cover a procedure, you will write it off in the Claim Edit
window.
Capitation
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 order to calculate the account balance differently for capitation, there is a box in the Procedure Edit window called "Capitation patient co-pay". This box will be blank for procedures covered by standard insurance or no insurance at all. For procedures covered by capitation, there will be a number, either 0 or another amount that is the patient portion. You will not normally have to change this since it will be filled in automatically. But if you have entered in the procedures before entering in the insurance information for that patient, then the easiest way to update the individual procedures is to use the Update Fees button in the Treatment Plan module. All treatment planned procedures will have all their insurance settings changed to that of the current insurance.
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. When the claim comes back, enter the payment. Again, the payment will not affect the patient balance.
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.