Our office has about 800 patients that use a specific DHMO plan/Cap plan which from the practice's start were put in as Flat Fee PPO's. Those plans are now changed to DMO/Cap plans, but my question is....now when checking out the patients only their fee is posted, not the doctors original fee. For example: a 2740-crown's office fee is $1,000, the patients charge schedule is $600 and the patient is charged out for $600, but where does the other $400 go if it does not show up on the transactions?
DMO/Capitation: The insurance plan pays a flat amount or "plan fee" and the patient pays the remaining amount. There is no write-off involved. Allowance tables can not be added to this type of insurance plan.
Method - Cap.
Total Fee: $63.00 = T from the ADA code fee schedule
Plan Fee: $50.00 = F from the Bluebook Ins.
Pays: $40.00 = I from the Bluebook
Pat Pays: $10.00 = P calculated in the Bluebook
P = F - I
Meaning the system will ignore the office fee and use the fees from the bluebook for the plan the difference between T ( total fee \UCR \ Fee0 \ office fee ) and F (plan Fee , allowed amount ) which usually is the write-off amount for %PPO plans for example is not even calculated for DMO/Cap plans . In the given example for Code 2740-crown's if you check the Bluebook entry for this ins plan it should look like this
Insurance payment : $ 600.00 Fee0 Amount : $1000.00
Plan Fee : $600.00
Copay : $0
so the total actual charge is 600 $ not 1000 $ for patients on this plan ( DMO\Cap ).
It has to do with how you set up the Bluebook.
You can either show the PPO Adjustment or only post the Plan fee, its really how your doctor wants to see it on the day sheet.
either way will still report accurately
Keep in mind, the bulk CAP insurance payment, should be posted to the Insurance Plan