Procedure Estimate Downgrades
Sometimes insurance will reduce payment for a procedure based on material (e.g. composite to amalgam or porcelain to gold). To account for downgrades in payment for certain procedures, Open Dental can automatically calculate downgraded estimates.
Example: If you submit a three surface posterior composite code on a claim, insurance may downgrade the payment to a three surface posterior amalgam, resulting in less reimbursement.
In Open Dental, downgraded estimates are based on insurance substitution codes and whether or not the insurance plan is set up to apply substitution codes.
- The substitution code fee is never more expensive than the original procedure code fee (e.g. amalgam is never more expensive than composite).
- To see an example of the math behind downgrades, see Patient and Insurance Calculations.
Downgrade Estimates for an Insurance Plan
When an insurance plan is set to downgrade estimates:
- The charted code is still billed to insurance.
- The procedure's substitution code will be used to estimate the insurance fee. If no fee is entered for the substitution code, the fee for the original procedure is used instead.
- The patient will usually pay the difference between the composite allowed fee and the amalgam fee.
There are two steps required to downgrade estimates for a plan.
- Associate the procedure codes with substitution codes. By default, Open Dental associates four composite procedure codes with corresponding amalgam substitution codes.
- D2391 (composite) = D2140 (substitute amalgam code)
- D2392 (composite) = D2150 (substitute amalgam code)
- D2393 (composite) = D2160 (substitute amalgam code)
- D2394 (composite) = D2161 (substitute amalgam code)
- Configure the insurance plan to apply the substitution codes. A plan can apply all substitution codes, or you can select specific codes to downgrade.
Step 1: Associate procedure codes with insurance substitution codes
Open Dental does this for posterior composites by default. You may want to add others (e.g. porcelain crowns that are downgraded to gold).
- In the main menu, click Lists, Procedure Codes.
- Make sure the correct fees are entered in the fee schedule for both the procedure code to be completed and the substitution code.
- Open the procedure code to be completed (double-click).
- In the Ins. Subst Code field enter the insurance substitution code. In the above example, composite code D2391 has an amalgam substitution code of D2140.
- Optionally set the "Only if" condition. Options are Always, Molar, SecondMolar. Examples:
- If a composite downgrade only occurs when performed on a molar, set to Molar.
- If a crown downgrade is usually done on a second molar, set to SecondMolar. Many offices charge the same for both types of crowns, so this setting is not as common.
- Click OK to save.
Step 2: Configure the Insurance Plan
By default, insurance plans are set to apply procedure estimate downgrades for all procedure codes with substitution codes (Don't Substitute Codes is unchecked). You can optionally control which procedure codes are downgraded.
- Open the Edit Insurance Plan window, Other Ins InfoTab.
- Make sure the option 'Don't Substitute Codes' is unchecked. This is unchecked by default and determines whether the plan calculates downgrades. This will affect all procedures with substitution codes, unless you specify which codes to include/exclude (see step 3 below).
- To control which procedure codes are downgraded for this plan, click Subst Codes.
Codes to Substitute: Procedure codes that will be downgraded to the substitution code's fee.
Codes to Exclude: Procedure codes that will not be downgraded. Instead the fee will be based on the charted procedure and substitution codes will be ignored.
Only procedure codes with associated insurance substitution codes will show as options. Column Descriptions:
- ProcCode: The 'charted' procedure code.
- AbbrDesc: The abbreviation of the 'charted procedure code.
- SubstOnlyIf: The Only if condition of the insurance substitution code associated with the 'charted' code.
- SubstCode: The insurance substitution code associated with the 'charted' procedure code.
- SubstDesc: The description of the insurance substitution code.
- To move a code from one grid to the other, highlight it, then click the right or left arrow.
- Click OK to save.
Do not Downgrade Estimates for an Insurance Plan
To turn off downgraded estimates for a plan, on the Edit Insurance Plan window, Other Ins Info tab, check 'Don't Substitute Codes'. All estimates for the plan will be based on the procedure to be completed and substitution codes will be ignored.
When an insurance plan is set to not downgrade estimates:
- The charted code is billed to insurance and used to estimate the insurance payment.
- If insurance downgrades the fee, the estimated insurance payment in Open Dental will be inaccurate (too big).
Frequently Asked Questions
Q. My insurance plan covers downgrades for some patients, but not all. How do I set this up?
A: You may want to set up separate insurance plans.
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