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carolyn621
Premolar II

INSURANCE Approved Amount vs Allowed Amount

@debp  @tamy @jfdias68 @carolyn621 @sonyap @joedindo 

Does anyone have the best way to calculate the copay when the Approved amount and Allowed amount are different, to calculate to the penny. This would be for mostly of Delta Dental plans when the office is a Premier Provider and the plan is PPO. I have always been told to divide the PPO payment into the Approved amount to receive the percentage.

                 Billed Fee  Allowed    Approved    Ded     O-Visit   CoPay   Pt Pmt     Plan Pmt

  $46.00$32.00$26.00$0.00$0.0080%$11.20$20.80

 

The formula/recommendation works well for this fee, 20.80 divided by 32 = 65%

In the case of other amounts, it results in calculations that are not exact, therefore the collected amount will either result in overpayment or underpayment, as in the following example (which is only pennies but this should be able to be programmed to calculate to the penny) .

          Billed Fee   Approved  Allowed  Deductible O-Visit  CoPay   Pt Pmt    Plan Pmt

 $121.00$98.00$80.00$50.00$0.0030%$89.00$9.00

For demonstration, the deductible is not used to calculate the % that would be placed into insurance calculation. 

30%x $80 = $24    $24 divided by $98 = 24.4897959%    $98 x 24.49% = $24.00

PW will not pick up two decimal places so the options are: 24.4 or 24.5. 

$98 x 24.4% = $23.91    OR       $98 x 24.5% = $24.01

The only way to have exact calculations is to have change the formula to:

Approved Amount - (Allowed Amount x Copay %) = Patient Payment

$98 - ($80x30%) = $98-$24 = $74.00    Exact to the penny.   No extra time to send a 1st, 2nd statement, no confusion for staff or patient. 

I don't want to have to refer to a binder for exact calculations. If that is the case, then why have PW?

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sonyap
First Molar I

Oh my goodness - you have put a lot of time into this!  My head is spinning!!  I hate to admit it, but I have never figured out a way to enter these into the blue book, so I don't.  🙄

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Lots of lookers on this subject without any similar issues. Sonya, Are you out of network and therefore collecting 100% of the fees? If not out of network, then how are you calculating to have a professional presentation.

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@carolyn621 We have three docs that are grandfathered in to the old Delta Premier plan and two new docs that are on Delta PPO and a different Premier schedule.  So it is pretty much impossible to give a professional presentation.  So we end up with a less than ideal presentation wherein the doctor writes in either the Delta fees or our adjustment figures so that the patient has a better idea of what their out of pocket will be prior to starting treatment.

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