PPO Fixed Benefit Insurance Plan
Set up a PPO Fixed Benefit Insurance Plan Type when the office is contractually obligated to reduce its fees as an in-network provider, and the insurance plan is paying a fixed amount.
This insurance plan type calculates write-offs, includes the insurance portion, and rolls the remaining amount to the patient.
On the Insurance Plan, set the following:
- Plan Type: PPO Fixed Benefit
- Fee Schedule: The carrier's fee schedule.
- Fixed Benefit Amounts: This is required. Choose the FixedBenefit Fee Schedule for this insurance plan. The fee schedule should contain the amounts insurance pays for individual procedures.
- This field is only available when the Plan Type is set to PPO Fixed Benefit.
Additional Information
Selecting this plan type sets all insurance categories with a coverage benefit to 100%. Insurance estimates come directly from the Fixed Benefit Amounts fee schedule.
Deductibles are only calculated for insurance categories with a coverage benefit. To calculate the deductible on a category that is not displayed in the Benefits window, add an Other Benefit.
The patient portion is calculated using the following formula: UCR fee - Write-Off - Fixed Benefit amount
Write-offs are usually calculated using the following formula: UCR fee - PPO fee. The difference between the two amounts is an automatic write-off.
If Use UCR fee for billed fee even if PPO fee is higher is disabled in Preferences, and the PPO fee is higher than a provider's UCR fee, the PPO fees are used as the billed fees. Enable the preference to use the UCR fees instead.
If the preference, Fixed benefit fee schedules treat blank entries as zero is enabled, blank entries in the Fixed Benefit fee schedule are treated as no insurance coverage (i.e., 100% patient responsibility). If the preference is disabled, blank entries are treated as no patient responsibility (i.e., 100% insurance coverage).
Claims automatically show the provider's UCR fee, regardless of the status of the Claims show UCR fee, not billed fee setting in the Other Ins Info tab of Insurance Plan window.