Category Percentage

Used to denote Plans that pay a certain percentage of each procedure or procedure type, such as 100% on preventative, 80% on basic, 50% on major. Category percentage plans can be used with or without Fee Schedules. In most cases, you’ll want to leave the “Fee Schedule” dropdown menu set to “none,” so that the provider’s fees are charged. If you know what fees the plan pays for each procedure, you’ll enter them as an Out of Network Fee Schedule and then select the corresponding Fee Schedule from the Carrier Allowed Amounts dropdown in the Edit Insurance Plan window. That way, the system knows the plan is only going to pay a percentage of the allowed fees and assigns any differences between the provider’s fees and allowed amount to the patient when creating estimates.

Set Up an Out-of-Network Plan with No Fee Schedule

1. Plan Type: Category Percentage
   
2. Fee Schedule: None
   

The provider's default fee schedule is automatically used to calculate procedure fees and estimates. Although this is the standard method for out-of-network plans, it can leave patients with unexpected balances if the carrier's allowed amount is less than the procedure fee. 

Set Up an Out-of-Network Plan with a Fee Schedule

1. Plan Type: Category Percentage
2. Fee Schedule: None
3. Carrier Allowed Amounts: Choose the carrier's out-of-network fee schedule of allowed amounts from your list or contact the carrier for a fee schedule and create a new fee schedule with the data if it's not already entered.
   

In the "Other Ins Info" tab, the checkbox next to "Claims show UCR fee, not billed fee" should also be checked as part of the setup. If the fee schedule provided by the insurance carrier provides the exact dollar amount that will be paid, be sure to set category percentages to 100% in the Insurance Benefits section too.

With this setup, the provider's fees will be used to determine the procedure fee, but covered amount estimates will consider the carrier's allowed amount, so patients have a better understanding of what their insurance will pay and what their portion is. 

PPO Percentage

Short for Preferred Provider Organizations, a PPO Percentage Plan works similarly to a category percentage, but you should use a Fee Schedule to denote your contracted amounts for each procedure. This way, your estimates show the anticipated write-off amount. Plus, it’s easier to track write-offs, production, and other essential metrics.

Set Up a PPO Plan and Track Write-Offs

1. Plan Type: PPO Percentage
2. Fee Schedule: The Carrier's Fee Schedule
   

The "Claims show UCR fee, not billed fee" checkbox does not need to be checked. 

Write-offs for being an in-network provider are calculated using the following formula: Write-Off = UCR Fee - PPO Fee. 

Write-offs are reported in a number of places, including Production and Income reports, the Daily Write-off report, the PPO Write-offs report, and the Receivables Breakdown report.

If the PPO fee is greater than the UCR fee, the system will generally bill using the PPO fee instead. This setting is managed in Account Module Preferences. 

Set Up a PPO Plan with Patient Co-Pays for Procedures

1. Plan Type: PPO Percentage
2. Fee Schedule: The Carrier's Fee Schedule
   
3. Patient Co-pay Amounts: Choose the carrier's co-pay fee schedule of allowed amounts from your list or contact the carrier for a list of co-pays and create a new fee schedule with the data if it's not already entered.
   

When creating the co-pay fee schedule, you'll enter the patient's co-pay amount for each procedure and leave any procedure with no co-pay listed blank. 

In most cases, you'll also set all percentages to 100% in the Insurance Benefits. This way, the system calculates that everything above the co-pay will be paid by the insurance. 

PPO Fixed Benefit

You’ll only use the PPO Fixed Benefit option if you’re in-network for the carrier and they pay a set amount for each procedure rather than a percentage. This way, the write-offs will be automatically calculated and tracked for you.

Set Up a PPO Fixed Benefit Plan

1. Plan Type: PPO Fixed Benefit
2. Fee Schedule: The Carrier's Fee Schedule
3. Fixed Benefit Amounts: The Plan's Fixed Fee Schedule
   

When you select "PPO Fixed Benefit" as the Plan Type, you will get a prompt indicating that all insurance categories are about to be set to 100%. Click "OK" to continue.

The "Claims show UCR fee, not billed fee" checkbox does not need to be checked. 

Write-offs for being an in-network provider are calculated using the following formula: Write-Off = UCR Fee - PPO Fee. The write-off will be automatic.

If the PPO fee is greater than the UCR fee, the system will generally bill using the PPO fee instead. This setting is managed in Account Module Preferences. 

The patient portion is calculated using the following formula: Patient Fee = UCR Fee - Fixed Benefit Amount.

Blank entries on a fixed benefit fee schedule are treated as zeros. Settings are found in Family Module Preferences. 

Medicaid or Flat Co-pay

When the Medicaid or Flat Co-Pay Plan Type is selected, the system will automatically calculate that all procedures have 100% coverage with no maximum or deductible. You will not be able to change any of the percentage amounts and write-offs are not tracked.

Set Up a Medicaid or Flat Co-Pay Plan

1. Plan Type: Medicaid or Flat Co-Pay
2. Fee Schedule: The Carrier's Fee Schedule
3. Patient Co-pay Amounts: The Carrier's Co-Pay Fee Schedule 
   

When you select "Medicaid or Flat Co-Pay" as the Plan Type, you will get a prompt indicating that all percentages will be cleared. Click "OK" to continue.

When creating the co-pay fee schedule, you'll enter the patient's co-pay amount for each procedure and leave any procedure with no co-pay listed blank. 

Capitation

Used with HMO and DMO plans, in which the patient typically pays a discounted rate for procedures, selection of the Capitation Plan Type will disable all percentages. The system will track any write-offs.

Note that patients should not have more than one capitation plan or you will need to manually change write-off amounts for each procedure on secondary claims. Production reports will also be inaccurate. 

Set Up a Capitation Plan

1. Plan Type: Capitation
2. Fee Schedule: None 
3. Patient Co-Pay Amounts: The Plan's Co-Pay Fee Schedule
   

When you select "Capitation" as the Plan Type, you will get a prompt indicating that all percentages will be cleared. Click "OK" to continue.

Note: Treatment Plans and the Account will show UCR fees, but it will not impact the patient's balance as procedures are completed.

Billing Insurance with Capitation Plans

Most capitation plans are not billed, though occasionally you may have one that will make a payment toward lab fees or similar. The billing process for a capitation plan is different than other insurance plan types.

1. From the Account Module, select the procedure you wish to submit a claim for and click "New Claim" at the top of the screen.
   
2. When the Edit Claim window opens, double-click the procedure and click "OK."
   
3. Change the "Fee Billed to Ins" amount and the "Insurance Estimate" to the amount the carrier will pay.
   
4. Click "OK" to send the claim. You can mark the claim as received immediately if you don't expect a payment or leave it as sent and track it with the Outstanding Insurance Claims report.
   

Processing Monthly Payments from a Capitation Plan

1. Apply payments as patient payments. Note that pay splits will be tracked as unearned income if Enforce Valid Paysplits is set to Enforce Fully.
   
2.  Add a capitation payment procedure for the full payment amount. Note that production values will be impacted with this method.
   
3. Apply payments as insurance payments. Note that payments will show on reports and deposit slips as insurance payments with this method, though additional steps are required.
   
1. Create a dummy procedure with no fee.
2. Add the capitation plan to the dummy patient.
   
3. Create a dummy claim with the dummy procedure on the dummy patient's account.
   
4. Add each payment By Total on the same claim.

Capitation Reports

1. Capitation Utilization Report: Run to show all procedures along with provider fees and patient co-pays for any given date range.
   
2. Production and Income Reports: Include production as Procedure Fee - Capitation Write-offs.
3. Aging of Accounts Receivable (A/R) Report: Exclude the special billing type used in your dummy account from the A/R report to avoid having credits show.