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All About Fee Estimates & Recalculating Fees

Faris Peerukannu Mohamed Kasim
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Let's explore the various aspects of fee estimates, recalculating fees, and auto fee recalculation.

Topics Covered

  • Fee Estimates
  • Recalculate Fees
  • View Fee Estimates from Appointment Slide-out
  • Auto Recalculation
  • Lock Fees & Unlock Fees 

Watch this video for a concise summary.

Fee estimates in CareStack are calculations that help determine the expected cost of dental services for a patient. They take into account various factors such as family maximum and deductible remaining values, in addition to individual maximum and deductible remaining values. The fee for a procedure code is calculated not only based on the individual's insurance details but also considering the corresponding family-level values.

Fee Color Indicator

During the treatment planning phase, the Total Fees of every code would be represented by 3 different colors (Green, Red, and Blue) depending on the corresponding fee schedule values and the current code statuses.

The description of each color is given below.

1. Red: The fee would be shown in red if the code is not in Completed status and if the displayed fee is different from the Fee schedule values.

2. Green: The fee would be displayed in green color if the code is not in Completed status and if the fee is shown as per the Fee Schedule.

3. Blue: The fee of the code will be displayed in blue color once the code is Completed. Irrespective of the fee schedule values, if the code is added as a completed code or is completed from any other status, the color of the fee would be turned to blue.

Fee Overlay

The Fee Overlay parameter under the Authorization Details grid lets the user know when a response from the primary or secondary Authorization is received. The fee set for the code will not change when an authorization response is received.

Fees for all codes in all statuses, except Completed and Rejected in the current treatment plan, will be recalculated with the new billing order. This billing order is set based on the current date and the effective dates of the patient's associated insurance plans. The Fee is recalculated based on the existing fee calculation mechanism, considering the associated Fee Schedules, Hierarchy, Table of Allowances, and Fee Registers. During recalculation, the fees will be coordinated in case of dual coverage.

Recalculation Logic

  • The initial value of the remaining deductible and individual maximum remaining will be dependent on the Patient's Insurance.
  • The value will be altered dynamically on the fee recalculation of the next code in the same flow. Any deductibles will be displayed in the Fee Overlay parameter.
  • If the Individual Maximum remaining has been depleted, the Total Fee will be shown as the Patient Amount.
  • The whole amount will be set as the Patient Amount if any of the following occurs:
    • When the UCR fee split is not required in the practice account.
    • If the "ABP" (Assign Benefits to Patient) flag is set for the patient.
    • If the insurance plan has the Create Claim option set to No.
  • After recalculation, the deductible used and the remaining values displayed below the treatment plan will be updated.

Impact of Fee Calculation on Family Maximum and Family Deductible Application

  • If a general procedure code is completed or deleted after it has been completed, the remaining family maximums and remaining family deductible values will be updated if the values are limited.
  • When the fee estimation is completed, the family maximum and family deductible values will be considered while setting the fee.
  • The family maximum remaining and family deductible remaining values will be the same for all patients within an Insurance Account (i.e., all patients sharing the same insurance subscriber).

Scenario 1

Updating the remaining deductible values on code completion for each plan,

Consider:

  • Patient Estimate = x
  • Insurance Estimate = y
  • Total amount = x+y = t
  • Remaining Deductible = z

Case 1: Remaining Family Deductible (z) >= Total amount (t)

  • The remaining Family Deductible gets reduced by the total amount; (z = z-t)
  • Since the remaining Family deductible is not zero yet, then it will be applied to the next code.

Case 2: Remaining Family Deductible (z) < Total amount (x+y)

  • The remaining Family deductible becomes zero since the whole of it was applied; (z = 0)

Scenario 2

In case, the individual deductible remaining value > family deductible remaining, then the individual deductible remaining value will be applied only till the family deductible remaining is met.

Updating Remaining Family maximum values on code completion.

Consider:

  • Patient Estimate = x
  • Insurance Estimate = y
  • Total amount = x+y = t
  • Remaining Family Maximum = m

Case 1:

  • Remaining Family Maximum (m) >= Insurance Estimate (y)
  • The remaining Family Maximum should be reduced by the Insurance Estimate; (m = m-y)
  • Since the Remaining Family Maximum is not zero yet, then it should be applied to the next code.

Case 2:

  • Remaining Family Maximum (m) < Insurance Estimate (y)
  • Insurance Estimate will become the Remaining Family Maximum; (y = m)
  • The remaining Family Maximum will become zero; (m = 0)

Scenario 3

Updating Remaining Family maximum values on code deletion for each plan. This update should be made only if the date of service of the code for which the payment is being posted falls within the plan year (12-month period after the respective plan reset date).

Case 1:

  • Remaining Family Maximum (m) + Applied Family Maximum (y) < Family Maximum (i)
  • The remaining Family Maximum should be increased by the Insurance Estimate; (m = m+y)

Case 2:

  • Remaining Family Maximum (m) + Applied Family Maximum (y) >= Family Maximum
  • The remaining Family Maximum will become the Family Maximum of the plan; (y = i)

Scenario 4

Updating Remaining deductible values on code deletion for each plan. This update should be made only if the date of service of the code for which the payment is being posted falls within the plan year (12-month period after the respective plan reset date).

Case 1:

  • Applied Family Deductible (z) + Remaining Family Deductible (r)< Family Deductible (t)
  • The remaining Family Deductible gets increased by the applied deductible; (r = r+t)

Case 2:

  • Applied Family Deductible (z) + Remaining Family Deductible (r) >= Family Deductible (t)
  • The remaining Family deductible becomes the Family Deductible of the plan; (r = t)

When you are in the appointment slide-out, you can view the fee estimates for the codes in the appointment. This will be useful when you have the patient in front of you, and you want an idea of the fees.

To view fee estimates from the appointment slide-out:

  • Checkmark the Show Fee Estimates box from the Appointment Slide-out.
    • When you do this, the Fee, Insurance Estimate, Discount, and Patient Payable columns will appear.

Auto Recalculate is a feature, if enabled, that will trigger CareStack to automatically recalculate treatments every time you visit the Patient's Chart, Treatment Planner, or Appointment Details. As a result, insurance estimates and billing orders need not be manually adjusted when changes have been made. In effect, CareStack will automatically refigure the amounts of insurance portions if you add new insurance or make changes of that nature. Click here to know more.

Watch this video for a complete understanding.

Practices can use the Lock Fees feature to lock a manually adjusted fee for a limited timeframe. The office can set the preferred timeframe as needed.

Lock Fees

Perform the steps below to lock fees while adjusting Fee Estimates.

  • Search for the Patient using the Global Patient Search Bar.
  • Navigate to Patient Overview > Clinical > Treatment Planner.

  • Click on the intended code to open the Fee Details slide-out.

  • In the Fee Details page, enter the new fee estimate as needed and click Save.

  • Once you have manually added the fee estimate, you will receive a toast notification stating 'Fee updated successfully' and the updated Fee will be displayed on the grid.

  • The manually added fee estimate will not be retained if the fee is not locked during recalculation.
  • Right-click on the Code and click Lock fees.

  • In the Lock Fee pop-up, the default Lock Period will be displayed.
  • You can either choose the desired number of days on the Set Lock Period or select a custom date.
  • Once complete, click Lock Fee.

Note: Once this is done, the fee will remain locked until the selected time frame/date expires. But you can also unlock the fees anytime you want to.

Unlocking the Fees

As soon as the fees are locked, you will see a lock icon next to the code. To unlock the fees:

  • Right-click on the Locked code.
  • Select the Unlock Fees option to revert the fee to its previously entered estimate.

Set Up Default Lock Period

To set the Default Lock Period, perform the steps below.

  • Navigate to the System Menu > Practice Settings > Fee Tables > Settings.

  • Click Edit.

  • Enter the fixed number of days to lock the fee estimates under Default Lock Period for Fee Estimates.
  • Click Save.

Practices can use this simple guide to learn everything about fee estimates and recalculating fees.

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