Posting Medicare payments can be a very frustrating process. You need to understand about deductibles, copayments, medigap vs. supplemental insurances, and whether these insurance pay for copayments AND deductibles. Many of the following posting examples have similar processes and you will learn as you go through them. These example are:

• A. Patient has Medicare and a Medigap Policy
• B. Medicare Patient, No Secondary, Has Paid No Deductible
• C. Medicare Patient, No Secondary, Has Some Deductible Left
• D. Medicare Patient with a Secondary Insurance that Does NOT Pay Deductibles!
• E. Medicare patient, Secondary Insurance Pays Deductibles!

A. Patient has Medicare and a Medigap Policy
In this example the patient has met all deductibles! (Thank goodness!)
The medigap policy pays for all the copayment (Warning-some medigap policies only pay for 80% of the copayment. This is why you must monitor your reimbursements for each insurance). You accept Medicare assignment, billed for office visit 99213 (office visit) and 92083 (visaul field test, extended) and charged $187.00 as seen below.

The charges posted area on the top of the Payments screen looks like this …


As you can see above, Medicare approves $132.85 (see the Appr$ column) but pays only $106.28 (80%, see the Actual$ column) as displayed in the top of the Payments screen (which of course you maintain religiously … right?). To start payment posting on either the Payments or Adminstrator’s screen do the following:

• Click in the PT field and select 2 from the pop-up list (Insur-payment) and press [tab].
• In Date enter the date of payment (today’s date may have already been entered for you. If left blank today’s date will be assumed when you bring the payment down. Press [tab] to go to the next field.
• In the Amt$ field enter the payment, $106.28. Press [tab] to go to the Reference field.
• In the Reference field enter just the check number (no extra characters like “ck#”, etc.) and press [tab].

Note: If a payment is coming from either a check or charge, Reference must contain information. If this field is left blank, you will get an error dialog asking you for the Reference!

In Source select “MC” for Medicare (PracticeMaker® will do this for you if you leave Source blank. It uses the code you entered in the Affiliate field in the Insurances module for the primary insurance).

Note: If you need to create a new Source or Affiliate because there is nothing to use on the list, you can enter new ones in the PickList User module on the Affiliates screen.

When you sure all data in these temporary fields is correct click the button to save the information.

At this point...
An insurance balance still remains. The primary insurance has paid and a secondary insurance (medigap policy) exists that can be billed. PracticeMaker® wants to assign the balance to this insurance and the dialog below appears.


In this case the patient has a secondary insurance and therefore you would click Sec. Doing this assigns the claim to the secondary insurance and the billing date (the date the bill was assigned to this carrier), As of... , is changed to today. Changing this date insures that the claim is properly aged!

If you click Patient instead you are given the dialog below where you can assign part or all of the balance to the patient. The dialog explains details about balances and puts into the field the expected copay.


If you click Adjust to the initial dialog you are given another dialog to confirm your adjustment action. The correct action, however, is to assign the balance to the secondary insurance.
Click in the PT field and select 2 for Insur-Payment. Today’s date is auto-entered. If the Date field is left blank, today’s date will be filled in when you bring the payment down.

Enter the amount paid, in this case $26.57 (the expected Medicare copayment) and click the  button.


Since you have received what is expected and there is no tertiary insurance except for the patient, click OK at the dialog above. This will adjust off any remianing balance (here $54.15) and automatically fill in the Line Post fields located at the right end of the Charges Posted lists. The finished payment section looks like this.


Other posting possibilities
Adjust off claim and ignore secondary insurance
You could, however, elect to ADJUST the claim and ignore the secondary insurance.


When you click Adjust, and you confirm the adjustment at the dialog below, a Payment Type of 9, “Adj-Ins” is entered, bringing the balance to zero.

Assign the claim to the patient
You can also elect to assign the claim to the patient and ignore the secondary insurance. If you click Patient, the balance due is assigned to the patient and you are given the opportunity to determine if the full or a partial amount will be assigned to the patient, or if you would like to cancel.


If you click Partial the amount you enter into the Amount to Assign field is used to create the "1-Patient Responsible" line item, and an appropropriate insurance adjustment is added.

If you click Cancel nothing else happens. This gives you a way “out” if you made a mistake!

 
The patient pays the expected amount
As discussed above, when the patient pays you have two choices. Either DELETE the line item with the Patient Resp posting, or, as recommended, do the following:

• Bring the Patient Resp lineitem up into the temporary fields by clicking the button. Note the message telling that you are Correcting payment line 2!
• Change the PT from 1 to the correct PT (since this will be a payment against the insurance side of the invoice, even though the payment is coming from the patient, select either a Copay or Deductible related payment types).
• Change the Date to today or whatever day you want the system to record payment received.
• Enter the check number only into the Reference field.
  

Press the button and the line will be corrected.


B. Medicare Patient, No Secondary, Has Paid No Deductible [top]
In many respects this was discussed above when the patient was assigned the partial OR full balance when we ignored the secondary insurance. In this example…

• The patient only has Medicare and you billed a 99214 ($85.00) .
• The patient has not met any of the deductible (rats!)
• This time the patient has to pay the full approved amount as the deductible.

Post a “zero” payment (include check # if other payments were on the check) as done on the first payment line. This is considered an insurance payment of $0.00. Click the button.


Since the patient has no other insurance to bill you get the dialog below. If you click Patient, you get the second dialog where you need to decide how much the patient gets billed. Clicking Full adjusts off the entire balance.

This is the same dialog as see above but this time it presents you with the information you need to assgn the balance to the patient. In this case, since the patient needs to cover the unpaid deductible, you would click Approved.
 
PracticeMaker® creates an adjustment line for the remaining amount! The completed example is below! AT this point you would want to select a Message Code for the statement that the patient will receive. You could print the statement now or set it to Batch for later batcg processing.


NOTE: When the patients pays the expected amount, go through the same process as described in Example 1!

C. Medicare Patient, No Secondary, Has Some Deductible Left [top]
This example requires a small amount of diligence to do correctly, and is basically handled manually. The patient ONLY has Medicare. You billed for a 99214 and charged $85.00. The patient has $20 remaining on the deductible.


The patient has $20 remaining on the deductible. Medicare approves $66.95 for this visit, therefore this leaves $46.95 for Medicare to consider for payment. Of this Medicare only pays 80%, or $37.56. The copayment for this portion would be $9.39 (multiply the actual payment by .25 to get this amount). In addition the patient owes $20 for the deductible.

At this point you could create one "Patient Resp" line for 29.39 and in the reference type in "deductible and copayment" so you and the patient know what is going on. On the other hand, you could create TWO separate line items, one for $20 (the deductible) and another for $9.39 (the copayment). The final posting looks like this after yoy click on the


Each time you bring down one of the line items you will be given a dialog similar to the one below. Click the Cancel button.
   
When the patient final pays you would bring up each Patient Resp line item and change the Pay Type to the appropriate code (here Copay-chk/chg). The final payment section would like this.

D. Medicare Patient with a Secondary Insurance that Does NOT Pay Deductibles! [top]
As with all these examples, you accept Medicare assignment and billed a 99214 for $85.00.

• The patient has $20 remaining on the deductible.
• Medicare approves $66.95 for this visit (you can plug your own numbers in here). This leaves $46.95 for Medicare to consider for payment, and of this they only pay 80%, or $37.56.
• The secondary insurance would be expected to pick up the rest (or $9.39). So you put this information into the payment fields and click the down arrow to save the payment. At the Insurance Balance Remains dialog you would click Cancel.
  

 

NOTE: Here is a tip. To find out quickly what the copayment is based on what Medicare has paid, multiply the payment by .25 to get your answer ($37.56 x 0.25 = $9.39, same answer as $46.95-37.56).

This time you will assign the insurance balance to the Secondary insurance. Hopefully, once the patient has paid the deductible and the secondary insurance has paid its share, the payment section will look like this! Once you click the down arrow to bring down the final payment, you get the dialog below. Click Adjust to have the computer adjust off the remaining balance. Note that in the example below, the original Patient Resp record was deleted and the deductible payment put in after the secondary insurance paid.



E. Medicare patient, Secondary Insurance Pays Deductibles! [top]
  This example is the same as the one above but this time the secondary insurance pays for BOTH the deductible ($20.00) and the copayment ($9.39). Medicare pays $37.56 as above and you post this by clicking the down arrow to save the payment. You are then asked to assign the balance to the secondary insurance and you do.


Eventually, the secondary insurance pays the remaining balance, and you post a second payment line, as shown above. Once you post the secondary insurance payment (and a balance remains) the dialogs above appears. Click Adjust at the dialog since the payment has satisfied both the deductible and co-payment portion of the claim.

Last updated 9/1/2004