Working with Insurance

Setting Up Insurance Estimating

When Insurance Estimating is enabled for a patient's insurance plan, WinOMS calculates the amounts in the Patient Due and Insurance Due fields. When posting charges or creating treatment visits, click the Estimate button to calculate the respective amounts. These amounts are also listed on the Patient Treatment Plan Proposal and Patient Treatment Plan Summary.

WinOMS enables you to set up estimating for insurance plans. To enable this feature, you must first update settings for the practice, and then for each affected plan.

Note:  This feature is available beginning in version 10.0.2.

Practice Settings

To update settings for the practice:

1. Select Tables > Practice > Practice Preferences.

2. On the Insurance tab, select Detailed Calculation.

3. Click Ok.

Plan Settings

Insurance plans often have different default coverage percentages for different categories of treatment. WinOMS estimates coverage using the following hierarchy:

• Covered % for a procedure code from the allowable schedule selected for the plan.

• Covered % for the procedure category if it is defined for the plan.

• Default % entered for the plan.

To update settings for a plan:

1. Select Tables > Insurance > Plans.

2. Use the Search Criteria field to select the plan. The data entry fields are displayed.

3. On the General tab, under Coverage Information:

• Click New. Select a Procedure Category, enter the % for the category, and click Ok. The coverage information is displayed in the Procedure Category list.

• Repeat to add categories/covered percentages to the list.

• Enter a Default % for the plan. The is the covered percentage that is used when listed categories do not apply.

Note:  You must have at least a Default % listed for the plan for insurance estimating to function.

4. Click the Fee/Benefits tab and select Fee Schedule and Allowable Schedule for the plan.

Note:  To update or copy an existing schedule, click Edit.

5. Use the Auto W/D Code field to select a code for automatic write-offs and discounts.

6. Enter an amount in the Auto W/D Amount field, if applicable.

7. Select the appropriate Estimation Method from the list.

   The following methods are available:

    

   DMO

   Charge Amount = NOT USED

   UCR = DMO allowable fee

   Ext = Optional. This field is treated as a percentage when provided.

   Insurance Percentage = NOT USED

   Ins Share = 0

   Pat Share = UCR

   Writeoff = 0

   When Ext is provided:

   Ins Share = UCR x Ext

   Pat Share = UCR – Ins Share

   Writeoff = 0

   Explanation:

   This calculation method replaces the office fee with the insurance UCR value.

   If a percentage is NOT provided, the full amount is the patient share and there is no insurance share and no writeoff. The UCR replaces the office fee at the ledger level.

   If a percentage IS provided, the insurance portion is the UCR multiplied by the percentage and the patient share is the difference between the UCR and the insurance share.

   There is no write-off in this method.

    

   INS UCR

   Charge Amount = Office Fee

   UCR = Insurance allowable fee

   Ext = NOT USED

   Insurance Percentage = NOT USED

   Ins Share = UCR

   Pat Share = Charge Amount – Ins Share

   Writeoff = 0

   Explanation:

   In this method, the insurance specifies the exact dollar amount that it covers for each procedure.

   The insurance share is this amount, and the patient share is the difference between the office fee and the insurance share.

   There is no write-off in this method. The difference between the office fee and the UCR is paid by the patient.

    

   % INS UCR

   Charge Amount = Office Fee

   UCR = Insurance allowable fee

   Ext = Percent of UCR that the insurance will pay

   Insurance Percentage = NOT USED

   Ins Share = UCR x Ext

   Pat Share = Charge Amount – Ins Share

   Writeoff = 0

   Explanation:

   In this method, the insurance specifies the UCR amount and the percent amount that the insurance will pay.

   The insurance share is the UCR multiplied by the percent coverage.

   The patient share is the difference between the office fee and the insurance share.

   There is no write-off in this method. The difference between the office fee and the UCR is paid by the patient.

    

   FFS

   Charge Amount = Office Fee

   UCR = NOT USED

   Ext = Optional. This field is treated as a percentage when provided.

   Insurance Percentage = Percent coverage based on procedure type

   Ins Share = Charge Amount x Insurance Percentage

   Pat Share = Charge Amount – Ins Share

   Writeoff = 0

   When Ext is provided:

   Ins Share = Charge Amount x Ext

   Pat Share = Charge Amount – Ins Share

   Writeoff = 0

   Explanation:

   In this method, the insurance does not provide a UCR, but does provide percent coverage values, either by procedure category—for example, anesthesia, x-ray, or consult—or a procedure-specific percent.

   If a procedure-specific percent is provided, this percent takes precedence over a category percent.

   The insurance share is the office fee multiplied by the percent. The patient share is the difference between the office fee and the insurance share.

   There is no write-off in this method.

    

   UCR + FFS + WO

   Charge Amount = Office Fee

   UCR = Insurance allowable fee

   Ext = Optional. This field is treated as a flat dollar amount when provided.

   Insurance Percentage = NOT USED

   Ins Share = UCR

   Pat Share = 0

   Writeoff = Charge Amount - UCR

   When Ext is provided:

   Ins Share = Ext

   Pat Share = UCR – Ext

   Writeoff = Charge Amount – UCR

   Explanation:

   In this method, the insurance provides a UCR fee. The insurance may also specify how much of the UCR fee will be paid.

   If only a UCR is provided, the insurance share is the UCR, and the patient share is the difference between the office fee and the insurance share.

   If an exact amount is provided in addition to the UCR, the insurance share is this dollar amount, and the patient share is still the difference between the office fee and the insurance share.

   The write-off amount is the difference between the office fee and the UCR.

    

   % UCR + FFS + WO

   Charge Amount = Office Fee

   UCR = Insurance allowable fee

   Ext = Optional. This field is treated as a percentage when provided.

   Insurance Percentage = Percent coverage based on procedure type

   Ins Share = UCR x Insurance Percentage

   Pat Share = UCR – Ins Share

   Writeoff = Charge Amount – UCR

   When Ext is provided:

   Ins Share = UCR x Ext

   Pat Share = UCR – Ins Share

   Writeoff = Charge Amount – UCR

   Explanation:

   In this method, the insurance specifies the UCR amount, as well as the percent amount that insurance will pay. This percentage may be a category percentage—for example, anesthesia, x-ray, or consults—or specific to the procedure.

   If a procedure-specific percent is provided, this takes precedence over the category percent.

   The insurance share is the UCR multiplied by the percent coverage. The patient share is the difference between the UCR and the insurance share.

   The write-off is the difference between the office fee and the UCR.

    

   Capitation

   Charge Amount = Office Fee

   UCR = Insurance allowable fee

   Ext = Required. This is a flat dollar amount.

   Insurance Percentage = NOT USED

   Ins Share = Ext

   Pat Share = 0

   Writeoff = Charge Amount – Ins Share

   Explanation:

   In this method, the insurance specifies the UCR amount and exact dollar amount per procedure that will be paid.

   The insurance share is the exact dollar amount provided. The patient share is always $0 in this method.

   The write-off is the difference between the office fee and the insurance share.

    

   % Capitation

   Charge Amount = Office Fee

   UCR = Insurance allowable fee

   Ext = Optional. This field is treated as a percentage when provided.

   Insurance Percentage = Percent coverage based on procedure type

   Ins Share = UCR x InsPercent

   Pat Share = 0

   Writeoff = Charge Amount – Ins Share

   If Ext field is provided:

   Ins Share = UCR x Ext

   Pat Share = 0

   Writeoff = Charge Amount – Ins Share

   Explanation:

   In this method, the insurance specifies the UCR amount and the percent coverage, either by procedure category—for example, anesthesia, x-ray, or consult—or specific to a procedure.

   If a procedure-specific percent is provided, this takes precedence over the category percent.

   The insurance share is the UCR multiplied by the percent. The patient share is always $0 in this method.

   The write-off is the difference between the office fee and the insurance share.

8. Ensure that the applicable Plan Maximum and Deductible amounts are entered for the plan.

9. Click Ok.

Related Topics

Working with Insurance Carriers

Working with Insurance Plans

Adding Insurance Plans

Adding Fee and Benefit Information

Adding Forms, IDs, and Notes

Working with Fee and Allowable Schedules

Skill Sharpeners