This section has the following examples...
- A. You participate and billed only for an office visit
- B. Billed for outpatient procedures
- C. Billed for BOTH an office visit AND a patient-only charge on the same invoice
A. You Participate with an Insurance and Billed only for an Office Visit!
This is pretty straight forward. You billed a 99202 and charged $85. The HMO approved only $47 and the patient has a $5 co-payment, which was already collected (hopefully). Therefore, the HMO pays you $42 and you need to adjust off the rest!
The first payment was added on the date of service on the Charges screen(hopefully).
Enter the check number into Reference (This field cannot be left blank!)
In Source select whatever is appropriate for this insurance. If you leave this field blank PracticeMaker® will fill it in for you based on the Source assigned to the carrier in the PickList User module. When you are finished with payment entry field click the
.
In the dialog above, since you accept assignment with this insurance, click Adjust, and the software will create an adjustment line for you. The completed payment section is below.
B. You billed for outpatient procedures [top]
These two images below show what happens when you do and not have the “51” modifier with regards to the expected reimbursements.
When it time to post payments on the Payments screen, the charges list shows you the approved amounts for each charge (see above). The use of the 51 modifier with the second procedure has changed the Appr$ by 50% (from $710.11 to $355.06). If there were a third procedures its approved amount would have only been 25% if the 51 modifier was also used.
In posting this charge let’s assume that you get paid the FULL expected amount. This would therefore by very straightforward. After posting and bring down the insurance payment you would adjust off any remaining balance.
The final payment area would look like this.
C. You billed for BOTH an office visit AND a patient-only charge on the same invoice [top]
One of PracticeMaker®'s strongest features, and unfortunately one that is not well understood, is its ability to have BOTH insurance and patient charges on the same invoice. Only charges on the insurance side of an invoice are printed on a claim form or sent electronically. The example below shows the finished charge area for both an insurance procedure of 99202 and a patient charge for VITAGLO vitamins.
To have both patient and insurance charges requires the use of two or more fee schedules. The A fee schedule is reserved for patient-only charges, while the other 14 can be used for insurance charges. In this example the 99202 has already been billed and the FS is correct for the insurance billed. When you start to create a new charge line, the FS for the insurance is used initially. After entering in the New Code you need to click into the FS and change the "fee schedule" to A as shown below. Once you do, the correct Item$ amount fills in. Next, enter the number of units you want to sell and click the
icon to accept the
charge line.
Now, posting your payment to this invoice also needs to be done properly. Since each side of the invoice, insurance and patient, has a charge there must be a payment to each side of the invoice, too. In this example, let's assume that the patient has a $10 copay in addition to having to pay $10 for the vitamins. Let's say the patient gives you a check for $20, the final payment posting on the Charge screen would look like this. Note that the PT of 3 was used for the copayment and the PT of 7 was used for the patient-only payment.
When the insurance final pays the posting would be similar to other examples, above.
last updated 9/1/2004