Open Dental Forum

Insurance companies are driving me crazy. Medicaid started it by designing plans with a copay per visit. Now some Medicare Advantage plans are using the same concept and they are taking it one step further by applying it to only some categories. For example, a $5 per visit copay on Dx, Preventive and Restorative.
I know there's a feature request for copays per visit (#2073), but I feel like there's someone in these insurance companies whose only job is to make life miserable for us.
Jorge Bonilla, DMD

I have one plan that covers $1000 per year. It pays 100% on the first $250 regardless of the treatment and then 75% of the any TX after until the $750 is used up. It doesn't not matter what is filed, it is reimbursed 100% until $250 and 75% after that...... Simple, but no way to enter that into OD that I know of.

Of course, the Medicare stuff has become even MORE complex as of January 2015... and I still can't work out how to build a fee schedule that will address it.

The deal is this:

There are maybe five codes we can bill to insurance (New pt and recall exams, BWX, and prophy). The pt is responsible for $15 for exams, $15 for BWX, and the prophy is covered at 100%.

Everything else is discounted at 15% off of the practice's UCR, and can't be billed to insurance.

Last year, of course, these plans were straight fee schedule, with the pt responsible for 100% of the charges. Easy-peasy. Now... I can't figure out how to do this to save my life.

Ideas?

Cheers from the Frozen Tundra of Pittsburgh...
Jennie

You'll need to make a fee schedule for it that reflects those fees and using category percentage type plan, place all categories at 0% coverage. Using the "Other Benefits" feature, add exams, Btwgs and prophy individual codes at 100%. Then you need to make a copay fee schedule that has the $15 for exams and BtWgs and $0 for everything else.