Provider and/or Clinic-Specific Procedure Fees
When entering procedure fees in a fee schedule, you can optionally enter fees that are provider and/or clinic specific. This can reduce the number of fee schedules you need. Provider and/or clinic specific fees are useful in the following situations:
- A PPO plan has different fee tiers depending on the provider (e.g. dentists have one fee, specialists have a different fee).
- Clinics have different fees depending on geographical location.
- A provider's fee varies depending on the clinic they provide service in.
Fee Logic: Open Dental automatically assigns the procedure fee based on the Fee Schedule Logic and the treating provider/clinic. When determining which fee is used for estimates when provider and/or clinic-specific fees exist, Open Dental will use this logic in this order:
- Clinic and provider override.
- Provider-only override.
- Clinic-only override.
- Global fee.
Enter Provider and/or Clinic Specific Fees
- In the main menu, click Lists, Procedure Codes.
- Select the fee schedule criteria on the right under Compare Fee Schedules. These options determine which fee columns and fees show in the Procedures grid.
Fee 1 options determine the fees that show in the Fee 1 column.
Fee 2 options determine the fees that show in the Fee 2 column.
Fee 3 options determine the fees that show in the Fee 3 column.
Fee Schedule: Click the dropdown or [...] to select the fee schedule.
Clinic: To enter fees specific to a clinic, click the drop down or [...] to select the clinic.
Provider: To enter fees specific to a provider, click the drop down or [...] to select the provider.
Clinic and Provider are only enabled if the Fee Schedule allows provider and/or clinic-specific fees (Use Global Fees is unchecked).
As you select criteria, the fees in the corresponding column will change to reflect the current fee entered for the fee schedule, clinic, and/or provider. The fee color is a quick method of identifying if a fee is global or specific. A color legend shows in the lower right. Customize colors in Definitions, Fee Colors.
- Click in a cell to enter the fee. Press tab to move from cell to cell for quick data entry. If you delete a fee override, the fee will revert to the global fee.
- When finished, click Close to save the fees and close the window.
To view all fees by procedure, double click the procedure, then click More next to 'View provider and clinic-specific fees'. See Enter Procedure Code Fees for more details.
For PPO Plan1, dentists Dr. Jones and Dr. Smith use the same fees, but Dr. Wilson, an endodontist, has different fees for some procedures.
- Create one normal fee schedule (e.g. PPOPlan1) and uncheck the 'Use Global Fees' box.
- In the Procedure Code List enter the dentist fees as the global fees and provider overrides for the endodontist.
- For Fee 1 and 2, select the PPOPlan1 fee schedule.
- For Fee 2, select Dr. Wilson as the provider.
- In the Procedures grid, Fee 1 column, enter the dentist fees. These will be the global fees.
- In the Fee 2 column, enter Dr. Wilson's fees when they differ. These fees will override the global fees when Dr. Wilson is the treating provider.
Clinic A, B, and C have the same UCR fees, but Clinic D has different UCR fees.
- Create one normal fee schedule (e.g. Standard Fees) and uncheck the 'Use Global Fees' box.
- In the Procedure Code List, enter the fees for Clinic, A, B, and C as the global fees. Enter clinic overrides for Clinic D.
- For Fee 1 and 2 select the Standard Fees fee schedule.
- For Fee 2, select Clinic D.
- In the Procedures grid, Fee 1 column, enter the standard fees for Clinic A, B, and C.
- In the Fee 2 column, enter the fees for Clinic D when they differ.
Dr. Jane and Dr. George are both specialists at Clinic A and their fees differ from the UCR fees of other providers. Dr. George also works at Clinic B and his fees there are different as well.
- Create one fee schedule (normal) for Standard Fees.
- In the Procedure Code List, adjust the fees:
Assign the Standard Fees schedule as needed. The fees will automatically adjust based on clinic and treating provider.
- For Fee 1, 2, and 3, select the Standard Fees fee schedule.
- For Fee 1, select Dr. Jane as the Provider.
- For Fee 2, select Clinic A and Dr. George.
- For Fee 3, select Clinic B and Dr. George.
- In the Procedures grid, enter the fees in the correct column.
Hygiene Procedures and Fees
When there are multiple providers who have different allowed hygiene procedure fees for the same in-network (PPO) insurance plan, it can affect the insurance and patient portion estimates for hygiene procedures (e.g. when one provider is 'premier' and the other is 'basic PPO''). Hygiene procedure fees are calculated based on the rate of the provider on the exam. If providers have different rates, the hygiene procedure's reimbursement fees will differ by exam, as can the estimated patient portion.
The best solution for this scenario is to err on the side of overcollection.
- Create one fee schedule (e.g PPO Plan 1). For each provider that might be on a hygiene exam, enter the highest allowed fee among the providers for each hygiene procedure.
- Assign the fee schedule to the patient's insurance plan.
- When charting and completing procedures, the higher fee will always be used to calculate both insurance estimates and patient portion. This is good business practice. The fee the patient will expect and be prepared for will be the higher fee. If the insurance payment ends up being lower (because the lower paid provider did the exam) you can then issue a refund.
Note: In this scenario, we do not recommend paying hygienists based on net production, as their compensation will vary depending on the provider on the exam. There is no current way in Open Dental to have an accurate picture of the hygienist's income. For providers that are paid on collection, base the rate on actual income, not production, because production values will be inflated.
For each hygienist, enter the highest fee for each hygiene procedure. Leave blank for non-hygiene procedures..
For PPO Plan1, prophy procedure: Dr. A has a fee of $200. Dr. B has a fee of
Insurance pays 80% ($160 for Dr. A, $80 for Dr. B).
Patient portion for Dr. A is $40, for Dr. B is $20.
- When entering hygienie procedure fees for each provider that might be on a hygiene exam, use Dr. A's fees (the highest).
- Assign the fee schedule to the patient's insurance plan.
When the hygienist does a procedure on Dr. A or Dr. B's exam:
- The fee will be $200.
- The estimated patient portion will be $40.
- The estimated insurance payment will be $160.
When the insurance payment comes:
- When Dr. A is the provider on the appointment, insurance will reimburse $160, and the writeoff and payment portion will be accurate.
- When Dr. B is the provider on the appointment, insurance will reimburse only $80. The patient will have overpaid their portion ($20), so reimburse as needed.