Fee generation is a complex process, and because of that we get this question a lot: Why don't I get the fee I think I should? With that in mind, let's explore how fee schedules work in WinOMS and what needs to be done to get the right fee for your circumstance.
Multiple Fee Schedules
All fees are based on simplified fee schedules; each procedure in the schedule gets a single fee assigned to it. Fee schedules can be attached to three different entities in the system – an insurance plan, a patient, or the practice. When a user enters a procedure code in the Charge Wizard for a particular patient, the software will search for the fee schedules in the order listed above on a charge by charge basis.
The first thing we have to do is determine which fee schedule we will use. An insurance plan’s fee schedule takes precedence over a patient’s fee schedule, and a patient’s takes precedence over the practice’s fee schedule. Therefore, our first step is to determine if we can bill this procedure code to the patient's insurance plan.
Fee Schedule on the Insurance Plan
When posting a charge, the we first look to see if the patient has any plans assigned to them. If not, we skip insurance fee schedules altogether. If the patient does have insurance, we check the procedure code next. If it is marked as “Not Covered by Insurance”, then we skip the insurance fee schedules. If the patient has insurance, and the procedure is not marked as “not covered”, then we have to determine which of the Insurance Plans governing the patient will be the Primary Plan.
Primary Plan is determined by the order in which the plans appear on the Patient Workspace and by the practice setting of which type of plan to Bill First -- Medical or Dental. If the practice is set to bill Medical first, we use the patient's first medical plan as their primary plan; otherwise, we use their first dental plan. We then check the procedure code to see if it can be billed to medical -- it is a medical code or has a dental cross-code.
If all that is true, then we will check the primary medical plan to see if it has a fee schedule and look up the procedure code on that table. If the code has a fee in the schedule, then that is the fee that is selected. If the code does not have a fee, or if the plan does not have a fee schedule, then we skip to the patient's fee schedule.
In cases where there is no valid insurance to bill, we skip looking at insurance fee schedules and look directly at the patient's fee schedule to determine the fee for the charge.
Using Other Fee Schedules
If the system determines that we should use the patient’s fee schedule, we look up the procedure code and bill the amount that is shown there. If we don’t find it, or if the patient does not have a fee schedule, then we skip to the practice’s fee schedule. Once we are using the practice’s fee schedule, we look up the procedure code on that schedule and bill the amount that is shown or $0.00 if no fee is listed.
Blue and Gray Fees
There is a difference between a blue $0.00 and a gray $0.00 on a fee schedule. A gray $0.00 indicates that the procedure code does not yet exist on the fee schedule, while a blue $0.00 indicates that the user entered the procedure as a $0.00 fee on the fee schedule. In the case of a blue $0.00, that is what we will bill (without looking at any other fee schedule).
If a gray $0.00 is found on a fee schedule attached to an insurance plan, the system will look to the fee schedule on the patient and then practice until it finds a “blue fee”.
Capitated plans are different – we don’t directly bill procedures to capitated plans. For procedures billed to these plans, we usually set the charge amount to $0.00. If there is a fee schedule on the plan, and if the procedure does exist on the fee schedule (is gray), this is an indication that the capitated plan DOES NOT cover the procedure. In this case, we bill the fee at the patient’s or practice’s fee schedule rate.