Many elements contribute to the calculation of procedure fees and insurance estimates. If treatment plan or procedure estimates are inaccurate, below are some troubleshooting hints.
Fee schedule can be set in several places and certain settings override others. See Fee Schedule Logic for an explanation of how a patient's fee schedule is determined.
- Edit Insurance Plan Window, Fee Schedule: Make sure the correct one is attached. If using the default fee schedule of the provider, the selection should be none.
- Edit Insurance Plan window, Other Fee Schedules: This is where co-pay and out of network (allowed) fee schedules are assigned.
- Edit Provider Window, Fee Schedule: The default fee schedule of the provider. Typically this fee schedule applies to patients who have no insurance or if a patient has an Insurance Plan with none selected for Fee Schedule.
- Edit Patient Information Window, Fee Schedule (rarely used): Only patients with a discount fee schedule should have a fee schedule selection here (e.g. cash only or Membership Plan). In most cases you will use the provider or insurance plan fee schedule.
If you recently updated a fee schedule, you may need to update fees.
- Global Update: In Fee Tools, click Update to apply fee changes to all treatment planned procedures at once.
- By Treatment Plan: In the Treatment Plan Module, click Update Fees in the toolbar. This will update fees for the selected patient only.
Below are items to check.
- Insurance plan order in the Family module.
- Fee schedule assigned on the Edit Insurance Plan window (see above).
- Insurance Plan Types
- Provider's fee schedule (Edit Provider window).
- Are there fees in the fee schedule? Procedure Code List
- Insurance Benefit Information - Simplified View
- Procedure Estimate Downgrades: By default, Open Dental automatically downgrades posterior composite fees to amalgam fees if:
- The composite procedure code has a amalgam substitute code.
- There is a fee listed for the amalgam procedure in the fee schedule.To change the default, check the Don't Substitute Codes on the Edit Insurance Plan window.
- For PPO: In the Procedure Code List check or compare procedure fee amounts in fee schedules.
- Is a fee schedule assigned to the patient on the Edit Patient Information window (Fee Schedule (rarely used)).
Claims already paid will affect insurance remaining. See Insurance Remaining Estimate Calculations for more details about how remaining insurance amounts are calculated.
To see an example of the math behind downgrades, see Patient and Insurance Calculations.