PPO Insurance Calculations

Below is an explanation of the math behind write-offs, covered amounts, insurance estimates, and patient portion for PPO Insurance Plan.

Sample fees:

Write-off: The difference between your office fee and contracted PPO fee.

Office Fee - PPO Fee = Write-off

$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 write-off from the office fee.

Office Fee - Write-off - 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

Write-off: 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 = Write-off

$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 write-off from the office fee.

Office Fee - Writeoff - Insurance Pay = Patient Portion

$150 - $23 - $40 = $87

For more information about downgrades, see Estimate Downgrades.