Estimating Insurance for Flat Fee Medicare Plans

To estimate insurance payments for flat fee Medicare plans:

Set up accurate payment values in the bluebook for all procedures.
If there is no bluebook entry for the flat fee PPO insurance plan, the percentages specified in the Coverage tab of the Insurance plan record are used.

The following table explains the insurance estimation calculations used for dental and medical flat fee Medicare plans. The calculations show the estimations when the deductible is subtracted first or last.

The calculations are based upon the following example: The fee is $88, the allowed amount is $75, the bluebook insurance payment is $60, the coverage is 80%, the copayment is $30, and the deductible is $25.

The insurance estimation calculations for dental and medical flat fee Medicare plans are:

Plan Type

Calculations

Dental Flat Fee Medicare Plan

Bluebook Entry

No Deductible

The allowed amount is subtracted from the fee. The difference is the estimated write-off amount. The estimated write-off amount is added to the insurance payment entered in the bluebook.

In the example:In the example:The $75 allowed amount is subtracted from the $88 fee, leaving $13. The $13 difference is added to the $60 insurance payment entered in the bluebook. The estimated insurance payment is $73.

Dental Flat Fee Medicare Plan

Bluebook Entry

Deductible Subtracted First

The deductible is automatically subtracted from the estimated insurance payment entered in the bluebook. The difference is added to the estimated write-off amount.

In the example:In the example:The $25 deductible amount is subtracted from the $60, leaving $35. The $35 difference is added to the $13 estimated write-off amount ($88 fee - $75 allowed amount). The estimated insurance payment is $48.

Dental Flat Fee Medicare Plan

Bluebook Entry

Deductible Subtracted Last

The deductible is automatically subtracted from the estimated insurance payment entered in the bluebook. The difference is added to the estimated write-off amount.

Dental Flat Fee Medicare Plan

No Bluebook Entry

No Deductible

The coverage percentage is automatically multiplied by the fee.

In the example:In the example:The 80% coverage percentage is multiplied by the $88 fee. The estimated insurance payment is $70.40.

Dental Flat Fee Medicare Plan

No Bluebook Entry

Deductible Subtracted First

The deductible is automatically subtracted from the fee. The product is multiplied by the coverage percentage.

In the example:In the example:The $25 deductible is subtracted from the $88 fee, leaving $63. The 80% coverage percentage is multiplied by the $63 product. The estimated insurance payment is $50.40.

Dental Flat Fee Medicare Plan

No Bluebook Entry

Deductible Subtracted Last

The coverage percentage is automatically multiplied by the fee. The deductible is subtracted from the product.

In the example:In the example:The 80% coverage percentage is multiplied by the $88 fee, leaving $70.40. The $25 deductible is subtracted from the $70.40 product. The estimated insurance payment is $45.40.

Medical Flat Fee Medicare Plan

Bluebook Entry

Deductibles Do Not Apply

The allowed amount is subtracted from the fee. The difference is the estimated write-off amount. The estimated write-off amount is added to the insurance payment entered in the bluebook.

Medical Flat Fee Medicare Plan

No Bluebook Entry

Deductibles Do Not Apply

The insurance coverage percentage is automatically multiplied by the fee.

In the example:In the example:The 80% coverage percentage is multiplied by the $88 fee. The estimated insurance payment is $70.40.