Setting up insurance plans correctly and using updated fee schedules is key to getting accurate treatment cost estimates. More accurate estimates contribute to higher case acceptance rates and help build good relationships with your patients. In this post, we’ll discuss how to set up four common plan types. Also see Part 2 in this series, which covers more complex plan types including Medicaid and Capitation plans.

Not sure what type of plan you have?

See our Insurance Plan Type Flowchart!

Tech Tip: Create fee schedules to ensure the most accurate estimates.
See this video for how to create and edit fee schedules.

PPO Percentage

PPO Percentage Plans are the most common insurance plan type, used for in-network plans where write-offs are tracked. These plans calculate write-off estimates and patient portions using the UCR fees and insurance fees.

Use the setup below:

In the Treatment Plan you will see your office fee (1000.00), the insurance fee (800.00), what insurance is covering (640.00), the write-off  (200.00 (the difference between the office fee and insurance fee)), and the patient portion (160.00).

In the Account, you will charge out the full office see. Once the claim is created, you will see the correct write-off and patient portion.

PPO Percentage without write-offs

If you are in-network with an insurance plan but are not tracking write-offs, use the setup below:

In the Treatment Plan, you will not see your fee. Instead, you will see the insurance fee (800.00), what insurance is covering (640.00), and the patient portion (160.00). The patient will not see the discount they are getting for being in-network.

In the Account Module, you will charge out the insurance fee. The patient portion will be correct once the claim is created. No write-offs will be noted.

PPO Fixed Benefit

PPO Fixed Benefit Plans are used when the insurance is paying a fixed amount for each procedure. These plans calculate write-off estimates and patient portions using fixed benefit amounts, insurance fees, and UCR fees.

For PPO Fixed Benefit plans, use the setup below:

In the Treatment Plan you will see your office fee (1000.00), the insurance fee (800.00), the fixed benefit amount (700.00), the write-off (200.00), and the patient portion (100.00).

In the Account Module you will charge out your office fee. The write-off and patient portion will be correct once the claim is created.

Category Percentage

When you are not in-network with an insurance plan, set the plan type to Category Percentage. These plans can use an out-of-network fee schedule to calculate more accurate patient portions. If you do not have an out-of-network fee schedule, you would not link anything under Carrier Allowed Amounts.

For out-of-network plans, use the setup below:

In the Treatment Plan, you will see your fee (1000.00), the carrier allowed amount (800.00), what insurance is covering (640.00), and the patient portion (the remaining 360.00).

In the Account Module, you will charge out your office fee. The patient portion will be correct once the claim is created.

If you need help troubleshooting how write-off estimates and patient portions are calculating, feel free to reach out to us, we’re here for you!

Don’t miss Insurance Plans Part 2: Complex Plan Types, which covers more complex plan types including Medicaid, Flat Co-Pay, and Capitation plans.