How to Improve Dentrix Insurance Estimates with the New Allowed Amounts Feature

If you participate in a PPO insurance plan and post your own fees to the Ledger, the Allowed Amounts feature can help you to show the patient a correct insurance estimate and calculate the necessary write-off adjustment.

When your office contracted with a Preferred Provider Organization (PPO) insurance plan, you agreed to charge those patients a fee set by the insurance carrier. This fee is sometimes known as a “negotiated,” “allowed,” or “contracted” fee. The insurance’s fee will often be lower than your office’s usual and customary fee.

Watch the Dentrix G7.6 and G7.7 New Features webinar to learn more about this feature.

Presenting correct insurance and patient estimates to your PPO patients can be a challenge if your office chooses to post your own fees in the Treatment Planner and Ledger. In the past, you’ve been left to calculate for yourself what the insurance will cover for each procedure and the difference between your charge and the allowed insurance fee to create a write-off adjustment. Now the Allowed Amounts feature will calculate these things for you!

When Should You Use Allowed Amounts?

You can use Allowed Amounts if your office is a participating provider with an insurance plan and you post procedures complete using your own fees. The Allowed Amounts feature will inform Dentrix of the contracted fee to base the estimate on, helping you present accurate estimates and make necessary write-off adjustments.

When Should You Not Use Allowed Amounts?

If your office posts procedures complete using contracted PPO fees, the estimates are typically already correct and don’t require the Allowed Amount feature.

If your office is out of network (OON) with the insurance plan, your patient will be responsible to pay your full fee, not the insurance’s contracted rate. Entering Allowed Amounts is not necessary.

Explaining Allowed Amounts

The Allowed Amounts feature was introduced in Dentrix G7.5 with limited functionality, handling write-off adjustments only. Beginning with Dentrix G7.7, Allowed Amounts now factor into the calculation of patient and insurance estimated portions.

To explain how allowed amounts work, let’s look at a sample scenario:

  • You completed a crown for your patient.
  • Your office fee is $1000, and this is the amount charged in the Ledger.
  • The insurance plan only allows you to charge $500.
  • The plan pays 80% of their allowed fee, which equals $400.
  • The patient will be responsible for 20% of the allowed fee, or $100.
  • Under the terms of the PPO, you must write off the difference between your fee and the contracted fee, or $500.

Without using Allowed Amounts, Dentrix will determine from the plan’s coverage table that crowns should be covered at 80%, but it will base the estimate on the $1000 fee that you charged (or $800). The estimated patient portion would be the remaining 20%, or $200. In this example, the estimated guarantor portion is double what it really should be!

To address the problem, you need to let Dentrix know what the fee is that the plan allows to be charged for the procedure. This will allow the 80% coverage to be multiplied by the contracted fee instead of the amount charged.

Entering Allowed Amounts

There are several ways to enter Allowed Amounts. They include the following:

  • Adding individual codes
  • Adding multiple codes by copying a fee schedule
  • Adding multiple codes by copying from another plan
  • While entering insurance payments

Adding Individual Codes

To enter individual procedures and their Allowed Amount, open the plan’s Dental Insurance Benefits/Coverage dialog box and select Payment Table and Allowed Amounts. Click the Add button (+). Type a procedure code and the allowed amount for that procedure. Add as many codes as you need and click Save when finished.

Add Multiple Codes by Copying a Fee Schedule

If you have previously entered the contracted fee into Dentrix as a fee schedule, you can copy those amounts into the table, open the plan’s Dental Insurance Benefits/Coverage dialog box and click Payment Table and Allowed Amounts. Locate the Allowed Amounts section at the right (1). Select the fee schedule using the Copy From menu (2) and click the Copy button (3). Follow the prompts to confirm your choice, and all procedure codes and amounts will be added into the table. Click Save to keep these changes.

Add Multiple Codes By Copying From Another Plan

If you previously entered the Allowed Amounts information into another similar insurance plan, you can copy the amounts from that plan into this PPO plan, open the plan’s Dental Insurance Benefits/Coverage dialog box and click Payment Table and Allowed Amounts. Locate the Allowed Amounts section at the right (1). Click the Select Insurance Plan to Copy From button (2) and follow the prompts to choose the other plan. Click Save to complete the changes.

While Entering Insurance Payments

Often the PPO’s allowed amount will come to your attention while you’re entering an insurance payment. When using the Itemize by Procedure option to enter the payment, you’ll see the amount paid, payment table entry, and the allowed amount for each procedure. Editing these fields will also update the amounts in the plan’s Payment Table and Allowed Amounts.

Note: If a Payment Table amount or an Allowed Amount does not apply to the procedure you are itemizing, you can leave those fields empty. Any numbers entered in these fields will update the plan’s Payment Table, which may affect insurance coverage estimates for all patients with have this insurance plan.

How It Appears

When an allowed amount has been entered, Dentrix will calculate the estimates according to the PPO plan’s negotiated rate. In the Ledger, Today’s Charges still reflect the amount you charged at your usual and customary office fee. The estimates reflect the amount expected from insurance based on multiplying the coverage percentage with the allowed amount.

In the example screens you’ve seen so far, you may have noticed that not every number perfectly reflects allowed amounts. The full amount will still be reflected in some areas of the Ledger (Today’s Charges and Expected from Dental Insurance), the Treatment Planner (Treatment Plan Case Total), as well as on Billing Statements. In future releases, Dentrix developers plan to continue to evolve the program to create better options and integration of Allowed Amounts.

Write-Off Adjustments

Allowed Amounts can also assist you in making write-off adjustments automatically while posting payments.

In the Ledger, from the File menu, click Insurance Payment Setup. At the top of the window, select the Default Insurance Write-Off Adjustment Type that you typically use to post insurance write-offs. Then open the Calculate Default write-off amount by difference between drop-down list and select Procedure Amount and Allowed Amount. If you work mostly with PPO plans, you may also choose to select Enable Automatic Adjustments for Insurance Payments.

After making those changes, the write-off adjustment will automatically be calculated for you and posted to the Ledger at the same time as you enter the insurance payment.

By using Allowed Amounts with your PPO plans, your patients will receive accurate insurance estimates, and your team will not miss the hassle of making manual calculations and adjustments. Allowed amounts is another great new feature in Dentrix!

Additional Information

By Ryan Beardall, Contributing Editor