Sometimes an Insurance Plan 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.
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.
- Downgrades can include or exclude write-offs depending on your insurance setup.
- To see an example of the math behind downgrades, see PPO 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 original allowed fee and the downgraded fee.
Set a Downgrade Universally for all Insurance Plans
For procedures commonly downgraded by most insurances, users can create codes that default to downgrades for all insurance plans.
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)
To create additional universally downgraded codes:
- 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.
- Double-click the procedure code to be completed .
- 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.
- Always: Always downgrade this procedure code.
- Molar: Only downgrade when procedure is performed on a molar.
- Second Molar: Only downgrade when procedure is performed on a second molar.
- Never: Never downgrade this code.
- Posterior: Only downgrade when this procedure is performed on a posterior tooth.
- Click OK to save.
Set a Downgrade on the Insurance Plan Level
By default, insurance plans are set to apply downgrades for all procedure codes with substitution codes (Don't Substitute Codes is unchecked). Optionally, insurance plans can have specific downgrades set, or universal downgrades can be excluded.
- Open the Insurance Plan, Other Ins Info Tab.
- 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.
- Select whether or not to calculate write-offs by checking or unchecking PPO substitution calculates writeoffs. The write-off is calculated using the office fee and and the fee for the originally charted procedure.
- To control which procedure codes are downgraded for this plan, click Subst Codes.
- Click + to add a new substitution code.
- When prompted, select the charted procedure code from the Procedure Code list, then type in the downgraded procedure code in the SubstCode column.
- Use the SubstOnlyIf column dropdown to select the condition.
- 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).
To exclude a specific procedure code from being downgraded, change the SubstOnlyIf column to Never.
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.