Tx plan estimating wrong

[sonyap]

This employer does not have any code specific estimating, but the insurance company does.  Why would this information not pull over from the insurance company estimating, since it is not available through the employer estimating?  We are participating, and I have our entire fee schedule plugged into Delta, along with percentages.

[jdowner]

In between the benefits and the code list, there is the information that tells you where the estimating is pulling from for the highlighted entry.

The currently selected code shows the estimating being pulled from the plan "Tester 2." Is that the employer/plan or the insurance company name?  

[sonyap]

Tester 2 is the employer/plan

[jdowner]

Okay.  This indicates that for at least the selected entry, it has some kind of estimating set up inside of the patient's employer/plan either in the code-specific estimating list or in the code range table. The estimating on the employer/plan would either need to be updated to be accurate or cleared so that it will look at the next estimating layer, which is the Insurance company profile's code-specific list followed by its code range table. 

[sonyap]

@jdowner there is nothing in the code-specific for that employer/plan, only percentages in the table.  Why would "generic" percentages override very specific per code figures?  Why wouldn't PW look at the most specific number first and then back out level by level?

What if the percentages were copied from the insurance company's table?

[jdowner]

By design, the estimating looked in this order

1. Employer/plan code-specific estimating
2. Employer/plan code range table
3. Insurance company code-specific estimating
4. Insurance company code range table
5. Office Wide code specific estimating
6. Office Wide code range table
7. Tx code Default insurance payment %

It goes down the levels until it finds estimating information.  So in this case, while there might not be anything on the emp/plan code-specific table, there is something on level 2 at the code range table. So this is where it will pull from and not look any further down the levels. 

It's not so much overriding the code-specific estimating from the insurance company profile, it is not even getting that far to see that information there exists to be used due to it seeing information in the employer/plan tables. 

you could use the copy from function to copy the code-specific estimating (fees and percentages) and/or the code range table from the insurance company into the employer/plan. It would then see that information on the emp/plan as its place to stop going further.  The other option if you want it to pull from the insurance company tables is to completely clear out the employer/plan estimating for the needed codes on the emp/plan for both code-specific and the code ranges. 

[sonyap]

@jdowner  - this is in response to your 10/10/23 post.  We have a plan where nothing is covered except for exams and cleanings.  How do we prevent the treatment plan from estimating anything for restorative work?

[jdowner]

You have potentially two options. 

1. Go into the code-specific estimating for the needed employer/plans and for those codes that are not covered, set the insurance payment method to option 3 "Only covered by capitation plan, or insurance does not cover at all."

This will make it so that those codes are not going to be covered and will not estimate anything. 

2. You can set the code range tables so that they cover the restorative codes and then set them to 0% coverage. As long as they do not have anything in the code-specific estimating for those individual codes, they will follow the code range table and estimate 0%

[sonyap]

@jdowner  This is what the particular benefit table looks like.  Is it failing to estimate properly because we don't have the code ranges in place?

[jdowner]

Maybe.  The first place to check is under the Code-specific estimating.  Do those codes have anything set up on them there? if they do, that's where it's going to pull estimating from.  If they do not, then it looks at the code ranges.  Then, if nothing is in the code ranges for them, it moves on to the next location to check.