The Procedure Module

updated 10/26/2007

The Reimbursements Section
This section has a scrolling, editable list of what each carrier pays for this particular procedure. The example below is for "99203". This is invaluable information. By looking at this list you can adjust your fees based on the maximum reimbursement of your insurances! If the fee you are charging is higher than your highest reimbursement, "Fee Acceptable" appears on the top of this list as seen here. Otherwise "Fees TOO low" appears instead. In the case below the fees are correct based on what you have entered into the "Fee A" field.

The fields of this section are:

Allow Sch is short for "Allowance Schedule". You can now assign a particular insurance carrier to a certain recurrent allowance schedule. For example, Medicare of PA and Medicare Railroad both use the same allowance schedule "MCR" because they all pay the same amount for each procedure.

Multiplier (MT) is usually "1", except when that insurance only pays a certain portion of its Approved amount. For Medicare this is usually ".8" for 80%.

Actual is the amount you get paid form the carrier once the multiplier is applied to the Approved.

Copay is the amount that another source must pay after the insurance pays its full amount. For Medicare patients where the multiplier is ".8" the copay would be 20% of the approved.

The Effective date field tells the software when this amount becomes effective. You should only have two reimbursements amounts per procedure with the same Allow Sch or insurance code.

Insur Code and Name has a pop-up list of all insurances in the Insurance Module. If you are entering your reimbursement manually select it from this list. Only fill in the Insur Code field if you are not selecting or entering an Allow Sch. The preferred

Mod is the date when this reimbursement record was last modified.

To delete a reimbursment click the trash can icon

. Next to this icon is a check box. When checked it flags the record for mass deletion when you are inside the Reimburse database itself!

The NU field stands for "not used" and when checked the record is no evaluated during reimbursement look-ups in the Billing Module.

How Reimbursements work
PracticeMaker® gives you two ways you can link expected reimbursements to a procedure. These Approved amounts appear on the right hand just of the charges list on both the Payments and Admin screen.

Using Allowance Schedule..the best method (The older method is mentioned at the end of this section)

Another term for "allowance schedule" is also fee schedule. However, I find this last term confusing.

This is by far the best method of tracking your allowances when multiple insurances pay the same for all procedures. Even though you may have dozens of Aetna records in the Insurances Module, many of them pay the same amount for the same procedure. In this case, you could create an Allowance Schedule, say "AEP" for PPO claims, "AES" for Aetna POS claims, and "AEH" for HMO claims. To do this just click into the Allow Sch field in the Insurance Allowances list shown above, press [esc] or [delete] on your keyboard and type in "AEP". This Allow Sch will now be added to the permament list so it can be used over and over again. In the example screen on the top of this section two Allow Sch's are displayed, AEP and MCR.

Note1 : An Allowance Schedule (AS) code can NEVER be the same as any insurance code you have the system. For example, you will likely have an "AET1" code in the Insurance Module and we never want an AS with the same value..trust me!
Note 2: Leave the Insur Code field blank with this method.

After you have created the allowance schedule you need to assign this schedule to each insurance that will use it. This is done in the Insurances Module as shown below.

You can have two Allowance Schedules for each procedure with the same code. IN the example at the top of this section, there are two BLU1 fee schedules, each with different Effective Dates. The date of the procedure guides which AS is use bythe system. If you have more than two simply delete the oldest one. You can always overwrite an older on with newer amounts and just change the effective date.

How do Allowance make there way in the Billing record?
This is a great question. I'm glad I asked it! Whenever you enter a procedure and then bring that procedure down from the temporary fields to the permament list for that invoice, reimbursement data is "looked up" from the Reimburse database and entered into the appropriate fields.

Using Insurance Code...the older method no longer recommended method
By selecting an Insur Code in the list above (the name appears after a good Code is selected), and entering data in all the fields, such as Approved amount and Effective Date, you will be able to tell during payment posting if the insurance paid you the correct amount for that procedure. This means that potentially there could be a record in the database for each procedure for each insurance.

Note: Leave the Allow Sch field blank with this method.

For example, if there are three Aetna's (AET1, AET2 and AET3) there will be three reimbursement records in the list and each could pay a different amount, or worse still the SAME amount which means you would have to change THREE records when the allowances change (hoepfully increase..yeah right).