Last updated 10/25/2007

Reimbursements or Allowances
If you participate with many insurance plans, this means that you accept their allowance as full payment for that procedure. This is called "participation". The Reimburse database stores all your expected reimbursements, or allowances, on any procedure for any insurance carrier. This way you can monitor how much to charge and if you got paid what you were supposed to.

The top of the Admin screen has the fields shown below. The Payments screen similar fields but charges cannot be edited in this section. The columns on the right side are extremely important. The fields Appr$, Actual$ and Copay$ show how much the Primary Carrier for this claim approves for that line charge.  If there is an associated multiplier (like Medicare’s 80% or .8) the calculated Actual$ amount is shown. Copay$ has the expected copayment, whether coming from an insurance or the patient.  The calculated totals tell you how much to expect for this claim. The values in these fields are "looked up" from values stored in the Reimburse database!

Please note: Do not post any payments until you fix any missing reimbursements. When you post a payment you need to make sure of the following before you post a payment.
  1. You have found the correct invoice and patient
  2. The charges you billed have all been properly considered and not recoded by the carrier.
  3. The amount of the insurance payment matches your expected reimbursements


This information is critical for monitoring invoice payments and the automated line posting system. When the payments you post equal the amount you expect based on the allowances you have entered, the invoice is considered clean and all goes well. If the payments you received do not match what is expected you will get warned and asked to resolve the problem manually.

Two methods of linking an insurance carrier to an allowance schedule.
The newest method for tracking allowances uses an "Allowance Schedule" to link the allowances together. For example, Medicare of PA and Medicare Railroad both approve the same amount for the same procedure. Therefore, I will use the "Allowance schedule" of MCR for these reimbursement records. This aspect is more fully explained in the Reimbursements section of the Procedures manual.

The oldest method used by PracticeMaker® creates a separate allowance record for each procedure for each insurance carrier. This means that for 30 Aetna's there could conceivably be 30 reimbursement records for any procedure, such as "99204". In the background the software creates a special "look-up code" for each reimbursement. For example, for three separate Aetna's (AET1, AET2 and AET3) there will be three database records (99204AET1, 99204AET2 and 99204AET3) and each could pay a different amount.

Adding a New Reimbursement using the older method
Note: This method should NOT be used unless the insurance carrier is rarely used and whose payment schedule will NEVER be shared with another insurance. I highly recommend you do NOT use this for typical commercial insurances like Aetna, Cigna or Medicare. Use the method referenced in the paragraph above. That being said...continue at your own peril!

When the Appr$ field is blank you must create a new "reimbursement" record before you post any payments. This will insure that the line posting is done for you automatically and not manually.

To create a record using this method, you would this click the  icon (its circles in red in the graphic above) and the dialog below appears. Enter the Approved amount, change the %Actual Pay if needed (Medicare is 80), and the Effective Date for this approved amount. Click OK when done.


Editing a Current Reimbursement
To edit click the icon on the same line (next to the ) as the procedure . A sample screen below shows two reimbursements, each has a different effective date.


[click here to enlarge above image]


In order for the system to help you determine the correct allowance for a particular procedure, you should only have two records per procedure. One for the current year (or time period) and another for the previous year (or time period).

Note: If you want to retain previous allowance information check off  the box BEFORE the insurance name. This will remove it from consideration. The message on the bottom says, "If an allowance is "NOT USED" (this year and previous ONLY!!!) check this box!".

 
The information in these fields is only as good as the user who constantly updates and monitors his/her reimbursements.  The updating of “reimbursements” is done from this section (and is discussed in the Administrator’s section of this chapter) or in the Procedures module!