What are co-payments?
The co-payment functionality lets you split the fee for a treatment between a patient and a third-party payer, such as ACC, MoH in NZ or DHS in AU.
The patient is only invoiced for their portion, the third-party contribution is tracked separately in Claims Management, and both are reconciled as claims are resolved.
Key terms used in this article:
Fee (total fee) - The total amount the practice charges for a service, as set in the fee schedule.
Third-party contribution - The amount a third party is expected to contribute, as defined in the fee schedule.
Patient amount (co-pay) - calculated as the practice fee minus the third-party contribution.
What are the different fee schedules in use?
Private fee schedule - The patient is invoiced for the full amount. There is no third-party involvement.
Co-payment fee schedule - The patient is invoiced for their portion only. The third-party contribution is defined in the fee schedule and sent to Claims Management to be tracked. The patient's account screen shows a pending amount for the expected third-party payment, so the patient is only left with the difference.
Fully funded fee schedule - The patient pays nothing and the third party covers the full cost. The full cost is sent to Claims Management to be tracked, and the patient's account screen shows a pending amount for the expected third-party payment.
For example, on a $200 treatment where ACC contributes $150, the patient is invoiced $50 and the $150 is tracked in Claims Management until it's reconciled.
How do I set up a co-payment fee schedule?
Go to fee schedules and either click '+New' to create a fee schedule, or select the pencil icon to edit an existing one.
Choose the 'Fee type': 'Private' (default), 'Co-payment' or 'Fully funded'.
Choose when the claim is created:
'Claim on charge' (after each invoice is created) or
'Claim at end of treatment' (when a treatment plan is closed).
Some fee schedules, such as MoH or ACC, have the fee type and claim timing fixed to comply with the scheme's rules.
For example, MoH requires claiming at the end of the course of treatment. Where this applies, you won't be able to change these settings.
How do I set treatment prices for co-payment and fully funded schedules?
For a fully funded fee schedule, add the fee to the normal price row for the treatment.
For a co-payment fee schedule, add the third-party contribution to the row below the practice fee.
Once prices are set, treatments charted under these fee schedules will calculate the patient and third-party split automatically.
How do I assign a different fee schedule to a treatment plan?
Treatment plans can now use a fee schedule that's different to the patient's default fee schedule. This means if a patient is normally on one schedule (for example, a private schedule) but needs treatment under an emergency arrangement (for example ACC), you don't need to change the patient's main fee schedule - you can set the fee schedule for that treatment plan only.
From the chart, click the dropdown against the treatment plan number to open the list.
Select 'Settings'.
Choose the fee schedule you want to apply to this treatment plan.
The fee schedule name is shown as a prefix to the plan name as a reminder. Dentally will ask if you want to convert all existing treatment on the plan over to the new fee schedule.
From then on, any treatment charted for that plan defaults to the plan's selected fee schedule rather than the patient's default fee schedule.
Please note: Only one claimable fee schedule is allowed per course of treatment.
For plans using a co-payment or fully funded fee schedule, two additional columns appear on the chart, showing the third-party contribution and the patient amount. Hover over any amount or total to see a detailed breakdown, including the third-party contribution.
You can expand a treatment item to see further detail, including the third-party fee.
This is editable and defaults to the amount set in the fee schedule, but it can be overridden if there's an error or if a prior approval indicates a different reimbursement amount. It's locked and set to $0 for private fee types. Deleting the contribution amount will set it to zero. To get it back, either re-type it, or rechart the service.
The totals at the bottom of the treatment plan also show the breakdown of patient and third-party contribution totals.
How do I charge and complete treatment under a co-payment or fully funded schedule?
Dentally's normal behaviour of combining all treatment charged on the same day into one invoice has changed for these fee schedules, so that claims can be reopened easily:
Separate invoices are created for each claim instead
Only one claimable fee schedule is allowed per course of treatment.
When you charge treatment under a fully funded or co-payment fee schedule, a "pending payment" entry appears on the patient's account.
This is not a real payment and isn't included in payment allocations or practice income - it exists to show how much is expected from the third party towards the invoice.
The patient's account balance reflects this pending payment, so the patient is only asked to pay the difference.
Depending on the fee schedule's configuration, a claim is created and appears on the claims management page either when treatment items are charged, or when the treatment plan is completed.
How do I generate invoices and statements with pending payments?
Invoices and statements are generated the same way as usual, with some added elements to show the expected third-party payment.
Co-pay invoice changes:
A new 'Pending' section displays the pending payment amount for the third party.
The total due reflects the correct amount the patient needs to pay.
Patient statement changes:
The amount expected from the third party is highlighted in a boxout.
Any pending amount included in the opening balance is also displayed.
Pending payments are shown on the statement so the patient's balance matches what they're expected to pay.
How do I take a payment from a patient with a co-payment?
When an invoice includes a third-party portion (for example, ACC), Dentally automatically creates a pending payment for that amount on the patient's account screen. This pending payment is deducted from the total balance, so the patient amount shows only what the patient is responsible for paying.
Open the patient's account screen.
Check the patient amount, which already excludes the pending third-party portion.
Take the patient's payment using the normal payments workflow.
For the full payments workflow, see how to take a payment.
How do I manage third-party claims?
Amounts to be claimed from third parties appear in Claims Management. You can progress a claim through the following states until it's resolved:
Ready to submit - the initial state of a third-party claim.
Manually submitted - marks the claim as submitted; the claim date is set to today when you change to this state.
Action required - flags that the claim needs attention.
Paid - the state used to record payment for the claim.
Rejected - marks that the claim has been rejected.
For Ministry of Health claims specifically, see how to use the MoH claim management tool.
Reopening a claim:
Locate the claim you want to reopen in Claims Management.
Click the '...' more options menu.
Select 'Re-open treatment plan'.
Confirm the action in the dialog that appears.
Please note: Claims can only be reopened when they're in the 'Ready to submit', 'Action required' or 'Rejected' states. Reopening a claim deletes it from Claims Management and puts it back onto the patient's chart.
The 'Generate MoH claims', 'Submit to MoH' button, and the 'Prior approvals' tab, are specific to Ministry of Health workflows and aren't used when managing other third-party claims.
How do I pay or reject a claim?
For co-payments and fully funded fee schedules, the third-party amount isn't paid immediately - it's tracked as an expected pending payment until you take action in Claims Management.
Locate the claim and set it to 'Paid'.
A dialog opens with the fee received defaulted to the expected pending amount.
If the paid amount matches the expected pending amount:
Click 'Confirm'. The pending payment is removed from the patient's account and replaced with the actual payment.
If the third party pays more than expected:
Enter the actual fee received. Dentally shows the overpayment amount.
Click 'Confirm'. The payment is created, the pending payment is removed, and an additional 'Claim Adjustment' transaction is created to allocate the overpayment.
If the third party pays less than expected:
You'll be given a choice of how to handle the remaining amount:
'Make an adjustment' - the pending payment is removed, the invoice is adjusted lower to match the underpayment, and the third-party payment is recorded.
'Transfer to patient' - the pending payment is removed, the third-party payment is recorded, and the underpayment amount is left open for the patient to pay.
'Keep remainder open' - the pending payment is reduced to the underpayment amount, and the third-party payment is recorded on the invoice. To record a second payment, select Paid (not the arrow beside it).
Please note: For fully funded claims, the option to transfer the underpayment to the patient is not available.
Rejecting a claim:
Set the claim to 'Rejected'.
You'll be given the same options as when paying a claim (adjust, transfer to patient, or keep remainder open), but no payment is recorded for the third party.
FAQs
Why is the patient balance lower than expected? Because Dentally excludes the third-party portion from the patient balance until it's resolved.
Where is the third-party amount recorded? In Claims Management, not in the patient's payable balance.
When is a pending payment created? When a claimable treatment is charged under a co-payment or fully funded fee schedule.
What happens if the third party pays less than expected? You can adjust the invoice, transfer the difference to the patient, or keep the remainder open, depending on your practice's workflow. Transferring to the patient isn't available for fully funded claims.
I'm charting ACC services, but the practice fee isn't correct. Dentally only ships with the expected ACC contribution. Practice needs to go into the Settings and add the practice fee to each of the ACC treatment on the total line.