Secondary Insurance Estimates

[atd]

Our secondary insurance estimates are not calculating the way I expect them to. It doesn't seem to be coordinating benefits from the primary insurance, and also does not calculate writeoffs correctly. Here are a couple of examples:
The primary insurance is a PPO plan (MetLife) and the secondary is also setup as a PPO plan(although it's actually a Medicaid insurance with 100% coverage).
Looking at the treatment plan:
1) Fee 230, Pri Ins 119.20, Sec Ins 74.94, Discount 81, Pat 0. The 74.94 ins estimate for the secondary should really be zero - since the primary paid more than the allowed 74.94 the secondary will not pay any more, and the writeoff should be 110.80.
2) Fee 67, Pri Ins 0, Sec Ins 18.71, Discount 15, Pat. 33.29. The Sec Ins is correct, but the discount should be 48.29 and the patient 0 since the secondary is set at 100% coverage for that service.

The same is happening when primary is category percentage and secondary is PPO.
1) Fee 67, Pri Ins 0, Sec Ins 19.49, Discount 0, Pat 47.51. The discount and patient amounts should be reversed.

From what I can tell the PPO calculations are only done on primary insurance. Isn't this a bug?

[jordansparks]

Automatic calculation of secondary insurance is really really complicated. Especially since primary frequently does not pay as expected. So let primary pay first, and then manually change the estimates that you now expect from secondary.

[atd]

I agree that secondary insurance estimates are complicated - but that's why it would be better to have the computer do the calculations than humans! I don't expect it will be accurate 100% of the time, but I think it could be significantly improved. In a typical year we send over 2,000 secondary insurance claims for approximately 700 patients. Having to catch and fix all of those manually would require an increase in staff.

The majority of our patients with secondary insurance have Medicaid as the secondary, therefore there will be no patient responsibility - but the way things are being calculated right now the treatment plan and account balances show the patient will owe money since the secondary PPO writeoffs are not being calculated. We would get a lot of phone calls if we started mailing treatment plans to Medicaid patients that showed they would owe money. I also found in some cases that the combination of the primary and secondary insurance estimates results in a credit on the patient's account since it's not coordinating benefits.

This is critical for us, so I'm going to submit as a feature request and hope it has a chance. If anyone else agrees with me, please vote for this!

[jordansparks]

In your example, you say that the secondary insurance is Medicaid. But then you say the secondary PPO writeoffs are not being calculated. So I'm confused which it is. Is it Medicaid or PPO?

[atd]

Technically they are Medicaid insurance plans, but I'm not using the Medicaid/Flat Copay plan type in Open Dental. I've set them up as PPO plans with 100% coverage because I needed to be able to report on the writeoffs and have more flexibility with what procedures/categories were not covered (i.e. ortho, implants). I also didn't like how the fees displayed in the account were the allowed amounts - with PPO you see the full fee and discount in the account.