Types of Insurance Plans 

In the Insurance Plan edit window, there is a Plan Type selection at the lower left.  The options for plan types are as follows:

Category Percentage
This is used for traditional percentage insurance plans.

Advanced usage "allowed": An allowed Fee Schedule can be used to get more accurate estimates. If you know the UCR fees for a plan but you are not contractually obligated to follow them, then you can use the allowed fee schedule in addition to the regular fee schedule for the plan. Set up a new fee schedule with the UCR fees.  In the Definitions window, the type should be "A" for Allowed. In the Insurance Plan edit window, set the main Fee Schedule to your standard fee schedule and set the Carrier Allowed Amounts to your newly created fee schedule.  All fees will then show as your standard fees, but when calculating estimates, the allowed amount will be used in the ClaimProcs window.   Percentages will be based on the allowed fee schedule. If the published fee schedule is showing exact amounts that will be paid, then set percentages for all categories to 100%. When using an allowed fee schedule, the patient will still be responsible for any extra amount that your office charges above the published fees.

Advanced usage "co-pay": Not typically used for this type of insurance plan.

PPO Percentage
Preferred Provider Organizations.  Use this only if you are a preferred provider and you have signed a contract with the insurance company to only charge a certain amount.  If you are not enrolled in the PPO, then use your standard fee schedule and use Category Percentage instead of PPO Percentage. If using category percentage, just understand that the insurance might not pay as much as if you were enrolled if your fees are higher than their UCR fees.

Set the Fee Schedule for the Insurance Plan to the fee schedule provided by the carrier.  This will be the fee that the estimates are based on, aka the "allowed fee". But the fee that shows for the procedure will be based on the standard fee. The standard fee is pulled from the fee schedule for the provider assigned to the patient. You don't have to worry about checking the box for "claims show UCR fee..." because they will already be showing your UCR fee.

There are two Reports which use the writeoffs to compare the reduced fees to the standard fees.

If the standard fee for the provider is lower than the PPO fee, then the PPO fee will be used.

Production and Income Reports:  There are two alternative ways that users might want to see insurance writeoffs on production and income reports:
1. Apply writeoffs to production when the insurance payment is made.  The advantage of this method is that history won't be changed.  But the writeoffs will be counted against production many weeks after the actual work was done. This is the method that is used on patient accounts.
2. Apply writeoffs to production immediately on the day of service.  This would be accurate if writeoff amounts didn't change later from the expected amount. when using this method, any changes to writeoff amounts later down the road will affect historical numbers. Both alternatives actually provide useful information.  It will depend on your unique situation as to which of them you find the most useful.

Advanced usage "allowed": Not used for this type of insurance plan. Setting an allowed fee schedule will have no effect, because the PPO mechanism is already internally making use of allowed fees.

Advanced usage "co-pay": If you have a copay amount that the patient is to pay for each procedure, then you may set up an copay fee schedule. This copay fee schedule can have just a few fees on it, with the rest blank. The amounts in this copay fee schedule will override the ordinary percentage calculations described above.

Medicaid
When setting up the Insurance Plan, set the Plan Type to flat co-pay. This disables all the percentages and establishes 100% coverage. Then, check the box for 'Claims show UCR'. If it applies, check the alternate code box. The alternate code for each ADA code can be specified in the Procedure Code Setup window. Then, when you send your claim, it will show the alternate codes and your UCR fees. Insurance estimates will not take into account any percentages, maximums, or deductibles. Set the Fee Schedule for the Insurance Plan to the Medicaid fee schedule.  Do not set the allowed fee schedule or the co-pay fee schedule.  If insurance does not cover a procedure for some reason, you will write it off in the Claim Edit window when the insurance payment comes in.

Capitation
Also known as HMO or DMO, capitation pays a flat fee every month to the office regardless of what work is done on the patients. Patients pay a flat fee for some procedures and no fee for other procedures. Sometimes, a fee for the lab portion of certain procedures can be billed to insurance. Set the insurance plan type to Capitation and assign your standard fee schedule. These fees will be displayed in the treatment plan and in the account, but they will not affect the patient's balance after they are complete. For any patient portions, set up the co-pay fee schedule with the amount that the patient is required to pay for each procedure.

In the rare case that you need to bill insurance, select the procedure from the Account module and then click the Ins Claim button. Before sending the claim, change the fee billed to the amount that the carrier is required to pay. Change the estimate to the same amount, then send the claim. Because the claim is for a capitation insurance plan, the amount expected from insurance will not be applied to the patient balance. When the claim comes back, enter the payment. Again, the payment will not affect the patient balance.

To enter the monthly payments as they come in from the carrier, create a dummy patient with the same name as the carrier. Apply all payments to that patient as patient checks. That way, they will show on your deposit slips. Functionality will later be added for better handling of capitation payments.

The utilization report can be run at the end of each month from the Main Menu under Reports, showing a list of all procedures performed for capitation along with the UCR fee and the patient co-pay.

Advanced usage "co-pay": If you have a copay amount that the patient is to pay for each procedure, then you may set up an copay fee schedule. This copay fee schedule can have just a few fees on it, with the rest blank.  The copay amount would be used in the ClaimProc window.