Category: Insurance

How to Enter a Large, Multi-patient Insurance Payment

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Normally every patient who receives payment from a single carrier-payer will have Insurance Plans and Policies that are linked to that single insurance carrier in SOS. See the article Understanding Insurance Carriers, Plans, and Policies. When that is true, making bulk payments is pretty painless. You enter the check, or EFT voucher, with its full amount for the first payment. When you complete the first patient’s payment, you select another patient related to the carrier, apply more of the same check or EFT voucher, and so on until the entire payment has been applied.

Manually splitting a single check across more than one SOS carrier

Nevertheless, mistakes in configuration can result in more than one of your SOS carriers in your list conveying payments in a single check or EFT. In that event, posting a payment will be a more tedious process of breaking up an EOB or EFT report into two or more groups to match the carriers used in your SOS data, entering a separate check voucher for each group, selecting the appropriate check voucher for each patient’s payments, and finally adjusting the voucher amounts to match the payments for all related payments.

There are several variations you can use to manually enter these cross-carrier payments accurately, but here is one procedure recommended by the SOS Support Team:

  1. Starting with the first patient on the EOB or EFT report, Open a new credit entry in the current daysheet.
  2. Select the Patient and the Payer, then select Check or EFT as the Credit Type.
  3. The next step, as usual, is to select an existing check or EFT voucher or to create a new voucher. As we are still working on the first patient, there will be no relevant voucher available, so create a new one by clicking the New button in the lower right corner of the voucher list.


    In the Amount field of the voucher, enter the full amount of the check or EFT.
  4. Upon saving the voucher, you will find yourself back on the Credit entry screen, and the full amount of the voucher will appear in the Credit Amount field. Jot down the name of the payer for which you entered the voucher.
  5. Confirm that the selection for the If Any Unappled Amount field is set to “Keep the unapplied amount on this Check/Voucher” as shown here:
  6. Highlight a charge in the lower area of the Credit screen and click the Apply Credit button.
  7. The Credit Split window will pop up, with the appropriate information for the charge you had highlighted when you clicked the Apply Credit button. SOS will assume that you are paying the outstanding balance for the charge, but if the payment is a lesser amount, change the value in the Amount To Apply field. If you are paying less than the full balance and would like to adjust or transfer a portion of the balance, you can also do that here. When done, click the Save and Close button to return to the Credit entry.
  8. If the EOB or EFT is paying any other charges for this patient, just repeat Steps 5 through 7 until you are ready to go on to the next patient. If there are no more charges for this patient, click Save and Close in the top toolbar to return to the Daysheet list.
  9. Now we are ready to enter a payment from the same EOB or EFT for the next patient, so create a new Credit, select the next patient and select the appropriate payer. If this new patient’s list of payers includes the same one used previously, the voucher you entered before will be available to select. Do so and loop through Steps 5 through 7 until finished with payments for this patient. If this new patient has a related, but different payer, proceed to the next step. Otherwise skip to Step 11.
  10. If there is no relevant voucher present to select, then you will have to enter a new voucher as in Step 3 above. As before, you will enter the full amount of the check or EFT for the voucher amount. Confirm the unapplied option with Step 5, jot down the name of the payer, then loop through Steps 6 and 7 until finished with payments for this patient.
  11. If there are no more patients left on the EOB or EFT, all that is left is to adjust the amount on each of the vouchers you created. Find that paper on which you jotted down the names of the insurance payers for which you created the vouchers for the EOB or EFT. (Tip: If you can’t find it, you can go to the Daysheet and recreate the list by looking in the Description column of each of the Credits you just entered.)
  12. In the main program navigation bar (usually on the left side of the screen, click Billing Lookups, then Insurance Carriers. Double-click the first payer on your list, the select either the Check Vouchers or EFT Vouchers tab, depending on whether you were paying from a check or from an EFT.
  13. Double-click the voucher that you created in the steps above. Now change the value in the Amount field to the actual amount you distributed while applying payments from this voucher. That corrected amount can be calculated two ways:
  14. Continue down your list of payers until you have adjusted the amount for every voucher you created during this procedure.

Managing Patient Insurance Payers (Policies)

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To add a new patient insurance policy, or to view the details of an existing policy:

  1. Find the desired patient in the Patient List.
  2. Double-click the row to open the Patient detail view.
  3. Click the Payers tab.
  4. If the Insurance Policies tab is not currently selected, click that tab to see the list.
  5. To add a new policy, you can do any of the following:
    • Press <CTRL><N> on the keyboard.
    • Click the first icon in the toolbar for this tab.
    • Right-click the list and select New from the pop-up menu.
  6. To view the details of an existing policy, just double-click the desired policy row in the list.

PatientPoliciesList.png

The Patient Insurance Policy detail view looks like this:

Policy DV.png

Notice that there are several tabs on this form:

  • Main has fields for the basics, such as the Insurance Plan, coverage dates, type of services being billed, type of policy, and over-rides for co-pay settings inherited from the policy’s Insurance Plan. On this tab you also can see current aging and balance data.
  • Managed Care Auths lists any authorizations. You can add new authorizations here, and view or edit the details of previously defined authorizations. For more information about Managed Care Authorizations see Adding and Changing Managed Care Authorizations.
  • Claim Form contains fields that are needed to submit a claim, ranging from the Insured’s ID Number (Subscriber Number) to “Accept Assignment”. These are fields that you will probably recognize immediately from the CMS 1500 form.
  • Patient Insurance Policy Attachments is a list of other documents associated with this policy. The most commonly attached document is a scanned copy of the patient’s insurance card, but there is no restriction or limit to the documents you can attach from this screen.
  • User Defined Fields
  • Change Log

See also: Understanding Insurance Carriers, Plans, and Policies

Handling Deductibles and Insurance Denials

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Deductibles

It is, at best, difficult to predict whether a patient will have met their deductible by the time a claim is processed. For this reason, most providers assume that payment will be forthcoming from the insurance payer. For this reason, healthcare providers routinely assign payment responsibility and submit claims as if any relevant deductible has already been met. If it turns out that the deductible has not been met, the insurer’s EOB will reflect that status, denying payment and handing responsibility for payment to the next insurance payer, or back to the patient if there is no other insurance to bill.

Recording the Insurance Denial

In order to record the denial and transfer payment responsiblity, you would use a Credit entry as follows, taking information from the insurer’s EOB:

  1. Open a new Credit entry from the Daysheet list.
  2. Select the appropriate patient account and Payer.
  3. Choose “DEN: Denial” as the Credit Type, and an appropriate Denial Code such as “DED: Deductible not met”. (If an appropriately descriptive code is not already in the pick list, simply add one using the New button at the bottom of the lookup list.)
  4. Leave the Credit Amount as “$0.00”.
  5. Highlight the Charge entry that was denied and click the Apply Credit button.
  6. The Credit Split window will open, showing the zero amount in the Apply A Credit Amount panel. To transfer responsiblity to the next payer, enter the amount to be transferred in the Optional – Transfer all or remaining charge split balance panel. SOS automatically determines and displays the next payer, which will be the next available insurance payer or, if no other insurance payers, the non-insurance payer, in that order.

Recording Claim Adjustment Reasons for Denials or Payment Reductions

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In order to successfully file secondary insurance, your Credit entries for the primary insurer, whether payments, adjustments, or denials, must include Claim Adjustment Reason codes to document how the primary processed the claims. Even when the primary payer made a payment, it will often be reduced by amounts referred to as “claim adjustments.” The specifics of these adjustments are critical to the secondary payer, so as you enter the primary payer’s payment, adjustment, or denial, it is essential that you also record the the Claim Adjustment Reasons (CARs) that appear on the primary payer’s Explanation of Benefits (EOB).

NOTE that there is no reason to enter Claim Adjustment Reasons unless you are submitting secondary claims for this patient and service.
  1. Start by entering a credit as you normally would. Highlight the charge you are paying and click Apply Credit to open the Credit Split window. Notice the second tab, Claim Adjustment Reasons.
  2. Before saving the Credit Split, be sure to select the Claim Adjustment Reasons tab and complete it using the information in the primary payer’s EOB, as explained in the steps below.

  3. The next step is to decide what the total amount of the adjustments is and what dollar amount is accounted for by each of the individual CARs. Here is a simple rule to use to determine what the total amount of the CARs will be:

    Service Fee  –  Primary Insurance Payment = Total CARs

    Example One: Your fee for a service is $150.00; the primary insurance company paid $80.00. If you subtract $150.00 – $80.00 you are left with $70.00. All of the Claim Adjustments (CARs) for the primary payer should total $70.00.

    What is accounted for in the CARs? The CARs are the reasons given by the payer for not paying your entire fee. You must enter the primary payer’s reasons and the specific adjustments or transfers so that the primary payer’s CARs can be included in the secondary claim. You will indicate if there was an adjustment made by the primary insurance for contractual reasons, if there was a patient responsibility for the service, if there was a disallowed amount, or any other reason the primary payer indicates.

    To continue the example from above: The fee for the service is $150.00 and primary insurance paid $80.00. The primary insurance contractually allows only $110.00 for the service provided so they made an adjustment of $40.00. The patient had a copay of $10.00 on this service and coinsurance of $20.

    Using the formula above,

    FEE – PRIMARY PAYMENT = CARs

    $150.00 – $80.00 = $70.00 ($40.00 + $10.00 + $20.00)

    So we are now ready to enter the information in Claim Adjustment Reasons. After selecting the Claim Adjustment Reasons tab, click the New button on the toolbar or press <CTRL>-<N>.

  4. On your EOB, you will see that each adjustment has a Group Code and a Reason Code. To enter the $40 adjustment, select the Group Code “CO” for “Contractual Obligations” from the drop list. In the first Reason panel select code “45” (“Charges exceed your contracted/legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule”). Under Amount, enter “$40” and under Total Unit Paid, enter “1”. In this example, there are no additional reason codes for Group CO, so save the screen and open another by clicking the Save and New button in the toolbar at the top of the window.

  5. In this example, our EOB also lists a patient copay of $10.00 and  patient coinsurance of $20. You will enter “PR” as the Group Code for “Patient Responsibility.” In the first Reason panel, use code “3” (Copay amount) and “$10.00”. The Total Unit Paid will be 1. In the second Reason panel, enter code “2” (Coinsurance Amount), “$20.00” and Total Unit Paid, as usual, is “1”.
  6. Save and close, taking you back to the Claim Adjustment Reasons list. There you will see:
    Group Code Total Amount Total Unit Paid
    PR $30.00 2
    CO $40.00 1

    The claim now balances. you have accounted for the full amount of the fee ($150) with your payment of $80 and your claim adjustments of $30 and $40.

Example Two: The fee for the service is $150.00 but the primary insurance did not pay anything because it went towards the patient’s deductible. $150.00 – $0.00 = $150 (Fee – Primary Payment = CARs), so your CARs must  account for the full $150.00. The EOB indicates the same maximum allowable for the service as in Example One, $110.00. The EOB indicates nothing about copay. So you will enter a $40.00 fee adjustment (Group CO, Reason Code 45) and the remaining $110 as Group PR, Reason Code 1 (Patient Responsibility). The total CARS will equal $150.00. Your Claim Adjustments screen will show:

Group Code Total Amount Total Unit Paid
PR $110.00 1
CO $40.00 1