Example Set 1: Handling Medicare Posting
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.
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 99214 and charged $85.00 as seen below.
The charge posting area looks like this …

example goes here

As you can see above, Medicare approves $66.95 (see the Appr$ column) but pays only $53.56 (80%, see the
Actual$ 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, $53.56. 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 message and be put back into the Reference field!
· 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 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.


3. In this case the patient has a secondary insurance (Blue Shield) and therefore you would click Insurance.
· When you click Insurance, the invoice is assigned to the secondary insurance (in this case Billed to: Blue
Shield of PA) and the billing date (the date the bill was assigned to this carrier), As of... , changed to today!
The Secondary Insurance Pays
· 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 $13.39 (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
Adjust and confirm at a second dialog as shown above. 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 you get the message below. The cursor is placed into the Amt$ field for you! Just enter
the amount due by the patient and press [enter]. However, the software will fill in the current total amount
due. If you agree with it just press [enter]. An insurance adjustment will be posted and the patient assigned
the remainder of $13.39. NOTE: The posting of a 1-Patient Responsible line item is TEMPORARY only
and needs to be changed in accordance with the received payment. The line can be deleted and a new line
created OR brought up and changed as discussed on the following page.

· If you click Full the full remaining amount is assigned to the patient, as shown below!
· 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), in this case 5 or Deduct-chk/chg.
· 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, as shown below. Please note, however, that in this example
the patient paid for the full remainder of the Medicare charge. In real life the patient would have paid for the
copayment portion and there would have been an adjustment.



B. Medicare Patient, No Secondary, Has Paid No Deductible
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) just as above.
· 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 $0.00.
· Since the patient has no other insurance to bill you get the dialog below left. If you click Adjust, a Pay Type
of “Adj-Ins” is entered, bringing the invoice’s balance to zero. But you don’t want to do that (NOT UNLESS
YOU WORK FOR NOTHING)!
· We would correctly click Patient, and at the next dialog on the right click Partial. You would then enter
66.95 into the Amt$ field and press enter. This amount is the allowed by Medicare in this example.
Note: If you click Full, the total remaining balance is assigned to the patient!
· PracticeMaker® creates an adjustment line for the remaining amount! The completed example is above!
You will get a reminder that there is still a balance due – since the only “payment” made was the adjustment.
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
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. Though you could create one Patient responsible line item
for $29.39 we prefer creating TWO separate line items, one for $20 (for the deductible) and another for
$9.39 (for the copayment). The final posting looks like this:
· Each time you bring down one of the line items you will be given a dialog similar to the one below left.
Click the Adjust button and then click Cancel at the next dialog.
· When the patient final pays you would bring up each Patient Resp line item and change the Pay Type to the
appropriate code. The final payment section would like this.
After changing the second Patient Resp line item you would let PracticeMaker® adjust off the remaining
balance.

D. Medicare Patient with a Secondary Insurance that Does NOT Pay Deductibles!
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.
· 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.
· Click Insurance. The invoice is assigned to the secondary insurance and As of... changed to today!
· At this point, you want to simply add a patient responsibility payment line (PT = 1), the amount, and in the
Reference field type deductible as one more reminder. Then “Add” this line to the payment portal.
· At this point you get the dialog box on the left. Click Adjust but at the next dialog click Cancel.
· At this point you can send a statement to the patient and include a message (such as DED1) stating that
he/she owes on their insurance deductible. The statement can be printed now or batched for later!


E. Medicare patient, Secondary Insurance Pays Deductibles!
· 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 below.
· Once you post the secondary insurance payment (and a balance remains) the dialogs abobe appear. Click
Adjust at the first dialog since the payment (hopefully) has satisfied both the deductible and co-payment
portion of the claim! Click OK at the second to complete the adjustment. The finished product is below.

Example Set 2: Commercial Insurance posting
A. You Participate with an Insurance and Billed only for an Office Visit!
This is pretty straight forward.
· You billed $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).
· Now, on the Payments screen, you want to post this HMO payment.
· Click in the PT field and select 2 from the pop-up list (Insur-payment) and [tab].
· Enter the Date of the payment and then in Amount enter $42.
· 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.
· You are finished completely the payment entry field click .
· In the first dialog below click Adjust since you got fully paid. At the second dialog confirm the adjustment
by clicking OK.
· After all is said and done, the payment should like this!

B. You billed for an office visit and did several unrelated minor procedures
Many carriers pay 100% for the first procedure, 50% for the second and 25% for each thereafter. Be sure you
are familiar with the expected reimbursement for each procedure! If you use the modifier “51” when you
entered your charges for the second and higher procedure, PracticeMaker® will calculate your total expected
payments (based, of course, on the expected amounts for each procedure you have previously entered in the
Procedures module!)
In the following example you posted an office visit and two unrelated procedures on the Charges screen.
When it comes to post payments for this invoice you do so on the Payments screen, and the charges list now
shows you the approved amounts for each charge. The use of the “51” modifier with the second procedure has
changed the Appr$ by 50% (from $88 to $44). 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 vert
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
One of PracticeMaker®;s strongest feature, 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.
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 the example below
we will show you the step by step posting of an office visit to a private insurance (fee schedule M) and a patient
charge for a product purchased (fee schedule A). This product, however, could be any uncovered medical or
surgical procedure.
· Let’s use the same $85 charge for the 99214 as used many times before.
· Now let’s add a product called TheraTears, procedure code THER. When first added to the invoice, the fee
schedule (FS) M is added automatically and no amount appears in Item$. This is because there is only an
amount in the A fee field in the Procedures module for the code THER.
· Since this charge is going to the patient we need to change the fee schedule to A. Therefore, simply click in
the FS field and change the fee schedule to A. This causes the correct amount to be filled in.
· Next, select the number of Units to sell and then click the down arrow. If, however, this is an inventoried
item, and there are not enough units in stock to cover this order, you will be a dialog telling you so.
Otherwise, the line will be accepted. The finished charge section is below.
· Note that in the totals section below, that $85 appears as the Insur total and $11 as the Patient.

· Let’s assume for a moment that this patient has a $10 copayment for the visit and also pays $11 for the
TheraTears, both with the same check. These initial payments, collected while the patient was in the office,
would be posted on the Charges screen.
· The insurance finally pays, and these payments are posted on the Payments or Administrator’s screen. The
final payments section looks like this.
· Note that even though the patient’s payment came from one check, the payment was applied against the
insurance AND patient side of the invoice using two different payment types. When the insurance paid, the
appropriate adjustment was made. The final totals section looks like this. Note that even though the patient
paid a total of $21, only $11 appears on under the Patient column. The remainder was paid to the
Insurance side of the invoice.



Example Set 3: Capitated Visit Posting
A. The patient has a capitated office visit and no “billable” services
PracticeMaker® has been programmed to help you adjust off that portion of an invoice that will not be paid
because of capitation. You should still select your E&M code as if the patient was NOT capitated.
In order for the following scenario to work , the patient’s primary insurance MUST be set to capitation in the
insurance module as show here.
· You performed a 99214, which has your usual fee of $85. The patient’s copayment is $10.
· After you correctly posted the $10 copayment you will get the following dialog.
· After clicking proceed (same as pressing [enter]) an automatic capitation adjustment is created and the final
payment section looks like this.



Other Billing Circumstances
Patient has a Tertiary Insurance

On occasion the patient has a third insurance you want to bill after the Primary and Secondary have paid or not paid.  In the case where the secondary insurance was the last carrier the claim was sent to or the Balance From carrier, and a balance still remains, you will get the dialog below.  

Click Insurance to assign the balance to the third insurance!
 
Resubmitting a claim to Medicare
If you need to resubmit a claim to Medicare because you forget to use a modifier, or something else that prevented you from getting paid for the services rendered by your Providers, do NOT post any amounts that were paid.  Otherwise, Medicare may think that the patient paid the amount owed and will in turn send YOUR money to the patient.

To resubmit claims to Medicare do the following:

• Use the Administrator’s screen which has access to adjust the Payment or Charge line items!

• Simply put the amounts paid in the Screen comment: field and leave the payment line item fields for each of the paid charges blank for now.
 

• Fix the problem(s) that caused Medicare’s under payment!

• If the claim is not assigned to Medicare then re-assign it to them and flag the claim to be in the next Batch!

• Once you get paid for the outstanding charges just put the amounts you wrote in the Screen comment: field back into the Payments for each of those line items.

That’s it for the billing examples.  Through practice and repetition you will learn how to quickly post payments, know which dialog you can breeze through and how best to maximize your payments!