PPO Fixed Benefit Insurance Plan

Set up a PPO Fixed Benefit Insurance Plan Type when you are contractually obligated to reduce your 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:

Note: The Fixed Benefit Amount box will only show if the Plan Type is set to PPO Fixed Benefit. A Fixed Benefit fee schedule is required.

This plan will set all insurance categories to 100% coverage. Insurance estimates come directly from the Fixed Benefit fee schedule.

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 will be an automatic write-off.

Note: Write-offs are reported in Production and Income reports, the Daily Write-off report, the PPO Write-offs report, and the Receivables Breakdown report.

If the PPO fee is higher than a provider's UCR fee, the PPO fees are used as the billed fees. To instead use the UCR fees, see Account Module Preferences.

To set how blank fixed benefit fee schedules are handled, see Family Module Preferences, Fixed benefit fee schedules treat blank entries as zero.

You don't have to check the Claims show UCR fee, not billed fee because the provider's UCR fees already show on claims. The correct insurance estimate (breakdowns) will show in the account after the claim is created.