Simplify PPO Insurance Estimation Using Fee Schedules

You can improve your PPO insurance billing processes by following these steps for setting up fee schedules in Dentrix.

Updated 6/30/20

In dentistry we have all heard the old adage “inform before you perform.” Part of that informing process is to make sure that we have provided financial estimates to patients in advance of treatment so they have an idea of what their out-of-pocket financial responsibility will be.

On the other side of the chair, we all know that it is much simpler and more cost effective for the practice to collect the patient’s portion at the time of service rather than attempt to collect after the patient leaves the office. For this reason, the dental practice benefits by knowing what insurance will cover so that it can collect from the patient at the time of treatment.

Yet knowing what insurance will pay has become more difficult with the increase in the number of patients covered by preferred provider organization (PPO) insurance plans. Fortunately, Dentrix has several tools to help you in calculating more accurate insurance estimates with these PPO plans. The most important of these tools is the use of fee schedules.

Since PPO plans rely heavily on their allowed fees as part of their benefit, being able to set up a unique fee schedule for each PPO insurance plan or group can greatly help you in calculating patient out-of-pocket costs. Dentrix allows users to create up to 999 fee schedules. Each unique fee schedule can be attached to an insurance plan or group. Once the schedule has been attached to the group, any patient covered by the group will be charged the allowed PPO charge instead of the office’s regular fee. The PPO fee will also show as the fee amount for any treatment-planned procedures.

Before you begin setting up fee schedules, you first should contact the PPO carriers to get the allowed fee schedules for all plans your office participates with. Once you have this information, you can set up fee schedules in Dentrix and then attach them to insurance groups.

To add a fee schedule in Dentrix, you will first want to name the schedule in the Definitions. From the Office Manager, select Maintenance > Practice Setup > Definitions. Select Fee Schedule Names as the Definition Type (Figure 1). Select an unused ID and then type a name for the fee schedule. Click Change to save the name.

Once you have named the fee schedule, you’re ready to define the fees using the Automatic Fee Schedule Changes tool. From the Office Manager, select Maintenance > Practice Setup > Auto Fee Schedule Changes . Select the new fee schedule that you want to set up. Select Copy Fee Schedule and select your office fee schedule. Click Copy.

Once the list of fees is displayed, enter the PPO allowed charge for each code by double-clicking the New Fee amount, typing the PPO allowed charge, and then clicking the green check mark or pressing Tab. For procedures not covered by the plan that you can charge your full fee for, add your office fee to the procedure.

After you’ve set up the fee schedule, you’ll need to attach it to the insurance group. From the Family File, select a patient who is covered by the insurance group. Double-click the insurance block. Click the Insurance Data button. Select the Fee Schedule you created (Figure 4). Click OK.

Finally, you’ll want to make sure that you use the DX2007F or DX2012F claim format to maximize your reimbursement. This claim format will send your full fee to the insurance carrier. From the Family File, select a patient who is covered by the insurance group. Double-click the insurance block. Click the Insurance Data button. Select the DX2007F or DX2012F claim format. Click OK.

Using the fee schedule tool will help to improve the accuracy of your insurance estimates and enable your staff to collect the patient’s portion more effectively.


Learn More

To learn more about using fee schedules to set up PPO plans, see the “Setting Up PPO Insurance Plans” topic in the Dentrix Help.

Read “12 Rules for the Insurance Game” and “The 5 Things Never to Say to Your Patients about Insurance” for more insurance management ideas.

Visit https://www.dentrix.com/products/eservices/ecentral/insurance-manager to see how Dentrix can help you manage your insurance processes.


By Alicia Owens, Dentrix Profitability Coach

Originally published in Dentrix Magazine, Spring 2014