RFR – Page 11 – SOS Resources

Understanding Billing Providers, Providers, and Billing Profiles

Posted on December 21, 2017 | by SOS Blog | Leave a Comment

In your use of SOS, you will find there are several sorts of “providers”, and it is pretty easy to confuse one with another.

To start, there are “Billing Providers”, which in the past used to be known as “Suppliers” on the paper claim forms. In short, a Billing Provider is an entity that files insurance claims. Sometimes the billing entity is a person, but more often it is a business such as a C corp, S corp, LLC, Partnership, or some other kind of legal organization. On paper 1500 claims, the Billing Provider is printed in the lower right corner. On electronic 5010 claims, the Billing Provider shows up in the 2000A and 2010AA loops. You might even think of Billing Providers as bank accounts rather than actual people. In SOS you can add, view, and modify Billing Providers by expanding Billing Lookups in the navigation panel, and opening the item called Billing Providers (Suppliers).

In SOS G5, a Provider, on the other hand, is most always an actual person. A patient can have an appointment with a “Provider”, but will never have an appointment with a “Billing Provider”. That would be like having an appointment with a bank account. A Provider can have different roles, such as primary provider, rendering provider, or both. A primary provider is the healthcare professional who has the primary responsibility for a patient’s care, even if she does not provide much of the direct care personally. A provider who personally provides the direct care is known as the rendering provider. In SOS you can add, view, and modify Providers, whatever their treatment roles, by expanding Common Lookups in the navigation panel, and then opening the item called Providers.

Prior to SOS G5, it was sometimes necessary to create multiple entries in the Provider List to handle different billing requirements or practice compensation policies. SOS G5 simplifies these situations by allowing each Provider (again, the Provider is an actual person) to have any number of Billing Profiles. Each of a Provider’s Billing Profiles details how the Provider will be presented on insurance claims and statements, but also how the provider will be paid by the practice for her work. Here is a quick example: in many group practices a Provider may bill and be compensated differently for patients whom she has brought into the practice personally, as opposed to patients who came to the practice as a result of the practice’s advertising or web site. Each of these scenarios can be covered by a different Billing Profile. For more specifics about the use of Billing Profiles, see Managing Provider Billing Profiles. In SOS you can add, view, and modify Billing Profiles by opening a Provider and selecting the Billing Profiles tab.

Managing Provider Billing Profiles

Posted on December 20, 2017 | by SOS Blog | 3 Comments

Prior to SOS G5, it was sometimes necessary to create multiple entries in the Provider List to handle different billing requirements or practice compensation policies. SOS G5 simplifies these situations by allowing each Provider (again, the Provider is an actual person) to have any number of Billing Profiles. Each of a Provider’s Billing Profiles details how the Provider will be presented on insurance claims and statements, but also how the provider will be paid by the practice for her work. Here is a quick example: in many group practices a Provider may bill and be compensated differently for patients whom she has brought into the practice personally, as opposed to patients who came to the practice as a result of the practice’s advertising or web site. In SOS you can add, view, and modify Billing Profiles by opening a Provider and selecting the Billing Profiles tab.

Whenever you create a new Provider, the system will automatically create a default Billing Profile with a matching code. In the example above, the Provider Code (prefix) is CG, and the automatically created Billing Profile Code (suffix) is also CG. If you would rather change the profile code to something else, you are free to do so by changing the value of Provider-Suffix Code in the first field on the Billing Profile form.

The fields on this form should look familiar to you, as they match fields on the main Provider form. In fact, SOS copies the values for each of these fields from the Provider form. In most cases, there will be at most a handful of fields that you might want to change from the defaults — usually just the Payroll Multiplier or perhaps the name to appear on insurance claims or one or more secondary ID’s.

Note, however, that there are some tabs on this form as well:

Billing Profile Fees
Carrier Specific ID’s

Creating a Carrier Plan Exception

Posted on December 7, 2017 | by SOS Blog | Leave a Comment

Carrier Plan Exceptions (Plan Exceptions for short) is a way of making accurate entry of charges as efficient as possible, even if a patient has an insurance plan that requires an unusual allocation of insurance and patient responsibility or mandates a maximum allowable fee that is lower than you normally charge. (Note that in older versions of SOS, Plan Exceptions were called “Carrier Exceptions”.)

Medicare is the poster child for insurance coverage that requires special handling for each covered service, and SOS Plan Exceptions are the best way to make it quick and easy to enter Medicare charges. Let’s take a look at an example, billing for an hour of psychotherapy, CPT 90837, when the patient’s primary coverage is Medicare Part B by a Medicare participating provider (PAR):

Provider’s standard fee: $150
Medicare’s PAR Amount: $129.31
Medicare’s Actual Reimbursement Amount: $97.72

The most the (PAR) provider may charge is $129.31, so that is Medicare’s maximum allowable fee and the provider will have to write off $10.69 (the part of her standard fee above $129.31). In addition, Medicare only pays this provider $97.72 for an hour of psychotherapy, so the patient responsibility is the remaining $31.59 (max fee less insurance payment amount). The fact that these rates differ for each CPT code means that manual entry of insurance and patient portions plus the adjustment would be tedious and error-prone drudgery for every single service entered for Medicare patients. Instead, SOS’s Plan Exceptions give you a place where you can store the critical amounts one time so that the splits and adjustments can be automatically calculated for you. You just select the patient, the provider, and the service code. The software does the rest.

Plan Exceptions detail a unique combination of a specific insurance plan, service code, and type of provider. When you add a new charge entry to the daysheet, SOS takes the service code of the entry, the patient’s primary insurance plan, and the type of provider (if relevant) and checks to see if there is a match with a Plan Exception. If there is a match, the plan exception is used to determine:

How fee responsibility should be split between insurance and patient’s responsible payers.
If any part of the fee should be immediately adjusted (written off).
The CPT (and optionally any modifier) codes that should be used for claim filing.
(Pro version only) The revenue code to use on Institutional Claims.

You don’t have to fill in every field, just those that differ from the defaults on the General tab. For example, if only the CPT code to be used on claims for this payer is different from that specified in the Service properties (Common Lookups > Services), that is all you have to enter in the Plan Exception.

Copay (patient responsibility) calculation

Although increasingly uncommon, some managed care insurance coverage still employs more complex rules than those in our example above, such as escalating co-pay amounts based on the number of previous treatment visits. If that is the case for a particular Carrier Plan Exception, you should select “Authorization settings” for the Calculate Copay From field and make sure that the relevant Authorization configuration is defined appropriately in the patient’s Insurance Policy.

Non-standard units

You can override the number of units entered on the Charge Entry form through the use of the Multiply units by value in the Plan Exception. Rarely there may be a situation in which a particular payer requires that services be reported in the claim based on a smaller time increment. For example, one payer might require you to report a treatment hour in 15-minute units, while most payers expect a “1” for the hour. In this situation you could set a units multiplier of “4” in the Plan Exception for this service/carrier plan combination. The units on your charge entry will show “1” in the Charge Entry in SOS, but come out as “4” on the claim for this payer.

Special CPT requirements

Let’s say that one of your Carrier Plans requires a different CPT code than the rest of your payers for the same service. You would then add a Plan Exception for that Plan and service shorthand code, specifying the required CPT code. Some SOS users instinctively think that they need to add a new service entry to the Services list just for Medicare patients. Not only is an alternate Service not necessary, but it would also cause problems when a patient’s primary insurance requires one CPT while the secondary insurance requires a different CPT. Use a single service entry and shorthand code for each service. Just add or adjust the appropriate Plan Exception when a special need arises.

UB Revenue Code

If you are using the Pro version of the software and file institutional claims (UB forms and/or electronic institutional claims), you also can specify a special Revenue Code when billing the service and payor designated for the current exception.

Understanding Insurance Carriers, Plans, and Policies

Posted on December 1, 2017 | by SOS Blog | Leave a Comment

In SOS G5 and later, insurance payers are defined as the entity from which you receive checks or electronic payments, the Insurance Carrier. A given Carrier, especially the larger ones, generally offer a variety of Insurance Plans, which specify the default details of the healthcare coverage provided to employees and other individuals through Insurance Policies.

Carriers write the checks. Aetna and United Healthcare are Carriers. Many patients may share the same Carrier.
Insurance Plans contain the default conditions of coverage, such as deductibles, co-insurance, and copays to save typing when you add new Insurance Policies for a patient. In addition, it is in the Insurance Plan that you will find Plan Exceptions. Exceptions are the key to rapid, accurate assignment of payer responsibility when adding new charge entries. Every Carrier has one or more Insurance Plans. Many patients may share the same Insurance Plan.
Insurance Policies include patient and insured identifying information, subscriber number (insured id), and other specifics the Carrier needs to process your claims. An Insurance Policy is unique to one and only one patient, but one patient may have an unlimited number of Insurance Policies.

The important thing to remember, starting with SOS G5, is that when setting up an Insurance Policy for a patient, you will be selecting the Insurance Plan that specifies the coverage rather than the Carrier-payer. Every Policy links to its Plan, and every Plan links to its Carrier, so when it comes time to apply payments or adjustments, the system knows which Carrier (payer) to pick.

Posting Your Daysheet

Posted on November 28, 2017 | by SOS Blog | 1 Comment

In SOS, the Daysheet is the screen that shows a list of recently created charge and credit entries which you have not yet committed to the permanent record. You can, for example, still delete entries while they are in the Daysheet. When you “post” a Daysheet, however, you make the designated entries a permanent part of your accounting and they can no longer be deleted. Until you post, the items in the Daysheet window are not included in billing runs or in accounting reports such as the all-important aging reports. How often you post daysheets is entirely up to you. You can post several times a day, or wait two or more days before posting. It is important, however, that you understand the following:

Items on the current daysheet do not appear in statements or insurance claims.
Items on the current daysheet do not appear in most accounting and management reports.

When you decide to post, you can post every transaction in the Daysheet, or just select specific transactions to be posted. You can even post a single transaction if you like.

Selecting transactions for posting

Before you start the posting process, tag (highlight) one or more rows in the Daysheet list. There are several specific icons that appear in the main toolbar at the top of the SOS screen while you are working on the Daysheet:

**Left to right:** **Tag all transactions, un-tag all transactions**, **print the selected transactions,** **post the selected transactions.**

First, keep in mind that the Daysheet is a list like most others in SOS, so you can easily filter the list by specifying values in one or more columns at the top of the list. For example, you can specify a particular patient name at the top of the Patient column, a particular provider at the top of the Provider column, or a particular user at the top of the Added By column. Doing so will immediately hide all rows that do not match your filter conditions. You can then selectively highlight the desired transactions using the following techniques.
If you want to print or post everything in the Daysheet, use the Tag All button (third button of the four shown in the image above).
If you want to print or post a group of consecutive transactions, click the first one to highlight that one, then hold down the <SHIFT> key and click the last one in the group to highlight everything in between.
If you want to print or post more than half of the transactions, first highlight the whole list using the Tag All icon, then hold down the <CTRL> key and click each of the rows you want to un-tag.
If you want to print or post less than half the list, you can reverse the above technique. Start by using the Un-tag All button (button four) then hold down the <CTRL> key and click the transactions you want to tag.

Preview and print the Daysheet

Once you have the desired transactions tagged, SOS suggests that you preview and optionally print a hard copy or generate a PDF of the Daysheet before posting. Click the Print Daysheet button (the second of the Daysheet buttons on the toolbar).

Posting the Daysheet

Once you have checked over your Daysheet preview and printed a hard copy or saved a copy as a PDF to a secure location (remember that this report contains HIPAA protected data), you are ready to post the Daysheet, moving the transactions to the permanent account ledgers. You will then be able to bill and include the data in your reports.

To post, simply click the Post Daysheet button on the toolbar. A reminder will appear. Just confirm that you want to proceed and the tagged rows will disappear from the Daysheet list. They then can be viewed and modified if necessary from the individual patient ledgers.

Category: RFR