Home User Manual Discussion Forum Search

Patient and Insurance Calculations

Below is an explanation of the math behind writeoffs, covered amounts, insurance estimates, and patient portion for in-network (PPO) insurance.

Sample fees:

  • Office Fee = $150
  • PPO Fee = $127
  • Deductible = $50
  • Covered Percentage = 80%

Writeoff: The difference between your office fee and contracted PPO fee.
Office Fee - PPO Fee = Writeoff
$150 - $127 = $23

Covered Amount: Subtract the deductible from the PPO fee (before applying the covered percentage).
PPO Fee - Deductible = Covered Amount
$127 - $50 = $77

Insurance Estimate: Apply the covered percentage to the covered amount.
Covered Amount x Covered Percentage = Insurance Estimate
$77 x 80% = $61.60

Patient Portion: Subtract the insurance estimate amount and writeoff from the office fee.
Office Fee - Writeoff - Insurance Estimate = Patient Portion
$150 - $23 - $61.60 = $65.40

Downgrades
In this example we will explain the math behind a two surface downgrade. For posterior composites, most companies still base their payment calculations on the corresponding amalgam code for the same number of surfaces.

Sample Fees

  • Office Fee for D2392 = $150
  • PPO Fee for D2392 (composite) = $127
  • PPO Fee for D2150 (amalgam) = $100
  • Deductible = $50
  • Covered Percentage = 80%

Writeoff: The billed code is always used for the PPO fee, so for a downgrade it uses the PPO fee for D2392 (composite). This is the last time the D2392 PPO fee is used.
Office Fee - PPO Fee = Writeoff
$150 - $127 = $23

Deductible: Subtract the deductible from the PPO Fee for D2150 (amalgam),
PPO Fee - Deductible = Covered Amount
$100 - $50 = $50

Insurance Estimate: Apply the covered percentage to the covered amount.
Covered Amount x Covered Percentage = Insurance Estimate
$50 x 80% = $40

Patient Portion: Subtract the insurance estimate amount and writeoff from the office fee.
Office Fee - Writeoff - Insurance Pay = Patient Portion
$150 - $23 - $40 = $87

For more information about downgrades, see Procedure Downgrades.

 

Open Dental Software 1-503-363-5432