Policy 1

The Policy 1 tab is where you enter the patient’s primary insurance information. Many of the fields included on this screen are similar to those included on the Policy 2 and 3 screens, with the difference being that they would apply to the secondary or tertiary insurance carriers if they were entered on those other screens.

Insurance 1: This field will be where you specify the Insurance Code for the primary carrier you wish to add to this case.

Policy Holder 1: Many people confuse the Policy Holder field with the Guarantor field. The Policy Holder field should contain the chart number of the patient or guarantor that holds the insurance policy.

Depending on circumstances, this may be a different person than the Guarantor that was specified on the Personal tab.

Relationship to Insured: The Relationship to Insured field corresponds directly to the Policy Holder 1 field. You will need to specify how the patient is related to the person listed as the Policy Holder 1.

Tips and Tricks:
The Policy Holder field for Medicare patients should always be the same as the patient Chart Number. Additionally, the Relationship to Insured field should always be set to self. Medicare does not offer family plans. Failure to accurately enter these fields for Medicare claims will result in claim rejections.

 

Policy/Group Number: You will find the patient’s policy and/or group number listed on their insurance card.

Policy Dates: These dates designate the policy effective dates. If these are applicable, they will also be listed on the patient’s insurance card.

Claim Number: Claim Number refers not to a standard Healthcare claim, rather a claim number that refers to a different type of insurance claim, such as an auto insurance claim, that is responsible for paying for the medical services being rendered. This field holds the claim number for that insurance claim.

Assignment of Benefits/Accept Assignment: This field determines who is going to receive payment for charges entered into this case. If you place a check mark in this field, that means the provider accepts assignment of the patient benefits, and the insurance carrier will send the payment directly to the provider. If you do not place a check mark in this field, the check will be sent to the Patient. The doctor’s office will be responsible for billing to and collecting from the patient in this situation. See Accept Assignment Handout.

Capitated Plan: Capitated plans pay a doctor or group of doctors a pre-negotiated amount of money per month to see a group of patients under a particular insurance carrier. These payments are not based on how many procedures are performed. The same payment will be made if no patients under that plan make a visit during the month. If this patient is part of a capitated plan, place a check mark in this box. See Capitated Plan Handout.

Deductible Met: This field is used to indicate whether the patient has met his or her annual deductible. When the deductible is met, click this box. The amount of the deductible paid is displayed in the Transaction Entry window. When the full amount has been paid, the program reflects the amount entered in the Annual Deductible field in this window in the YTD field in Transaction Entry. In other words, if the patient has a $250 deductible and the Deductible Met check box is checked, then the YTD field also reflects $250. This field is reset annually.


Annual Deductible: The Annual Deductible field is a reference field that will be displayed within Transaction Entry. If you know the amount of your patient’s annual deductible, enter it here.

Copayment Amount: Copayment Amount allows you to enter in the amount of the copay that this patient has for each visit. This field will display within transaction entry as the Policy Copay. This field is a reference field only. It will not automatically enter a copay for you. You will not be able to bill a patient for a missed copay until after the insurance carrier has paid. You will not be able to enter the copay reference as a percentage. It is strictly a dollar amount copay.

Insurance Coverage By Service Classification: The main function of Service Classifications is to provide a more accurate division of the patient and insurance portions when transactions are totaled. It is based on the premise that all similar procedures are reimbursed at the same percentage rate by the majority of carriers.

Because a carrier doesn’t normally pay the same percentage for every type of procedure, it is essential that procedures be divided into service classifications in order to assign the proper percentage to each class. These are set up at the time the procedure codes are created and, although they can be changed, they cannot be deleted.

A common example of the variation is the difference in percentages paid for office visits and those paid for lab work. Normally, office visits are paid at 80%, while lab work is covered at 100%. To handle this difference, when the procedure codes are created, office visits are put in service Class A (paid at 80%) and lab work is put in Class B (paid at 100%). In the Case (Policy 1, 2, and 3) windows, in the Service Classification fields, A shows 80% and B shows 100%. These classifications are used in calculating allowed amounts (Apply Payment/Adjustments to Charges window).

In the Insurance Coverage Percents by Service Classification fields, indicate the percentage amount of coverage indicated in the applicable insurance policy. There are eight fields to enter Service Classifications. You assign the fields. Field A is generally used for common procedures, and Field B could be for surgery or lab charges. Field C could be those services that are not covered by most insurance policies, etc.

The Service Classification fields in this window are completely separate from the 26 Charge Amount fields (A – Z) provided for in the Procedure/Payment/Adjustment edit window, Account tab.   The values for the Service Classification fields can be anything between 0% and 100%. Place a zero default for procedures not covered by the insurance carrier. Any of these figures can be changed by typing over the number, and the dollar amount charged can be overwritten in Transaction Entry.

Policy 2

Crossover Claim: The Crossover Claim field is the only field that is different in functionality from the Policy 1 tab. This field designates transactions entered under this case as crossover transactions. This means that the Primary insurance carrier will be forwarding the claim to the Secondary carrier. If this is the case, you will not want to print or send a secondary claim manually, as it would be a duplicate claim. If this box is checked, secondary information will be included on Medicare claims (for Medigap crossovers). Additionally, you will not be able to print or send the secondary claim for these transactions.

Policy 3

There are no fields on this tab with different functionality than the fields listed for Policy 1 or Policy 2.

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Account


Assigned Provider: The Assigned Provider is another required field. Because the Case is used to hold related groups of transactions together, each of those transactions must be linked to a provider. This provider will be the provider who defaults as the provider on each transaction entered under that case. When creating claims, you are given the option to create claims by assigned provider or attending provider. If you create claims by assigned provider, the provider entered into this field in the case screen will be the provider whose information is listed on the claims created for transactions entered under this case.

Referring Provider: In the chapter dealing with setting up a referring provider list, we discussed some of the reasons a patient would need to have a referring provider entered for them. It is imperative that you enter the provider into this field. This field will affect both paper and electronic claims.

Supervising Provider: There are some medical procedures that can be performed by people who are not doctors. These procedures are usually performed by Registered Nurses or Physicians Assistants. Whenever billing is done for these procedures, there must be a designated Physician who is “Supervising” the medical care offered by these professionals.

Referral Source: We have not yet discussed what a referral source is. This field is used to track patient responses to the question “How did you hear about us?” You would create a referral source for each unique answer to this question. For example, if you have an ad in the yellow pages, you would want to create a referral source for Yellow Page Ad. If you utilize this feature, you will be able to report on how much business your office is receiving from different sources.

Facility: The facility field is where you select the facility that will default into the Facility field available in Transaction Entry. In versions prior to Medisoft v11 this field WAS the field you would modify if you wanted to change the facility information on the claim. In Medisoft v11 and higher, we have the ability to modify the facility on a transaction by transaction basis.

Case Billing Code: The case billing code will default to the value entered in the Patient Setup screen as the Patient Billing Code. You can change this value on a case by case basis. Keep in mind that most reports that filter for billing codes do so based on the PATIENT billing code, not the case billing code.

Price Code: When entering the price code field, you will need to think back to the procedure code setup chapter. When entering your procedure codes, you were given the option of entering in various prices that were designated by a letter A through Z.

The Price Code field is where you designate which of these prices will default into transaction entry when the procedure is entered into Transaction Entry. The value you enter should be the letter of the price you wish to assign to this case.

Tips and Tricks:
You will want to make sure that each of your procedure codes follows the same pattern for prices entered. For example, Charge Amount C would be the field used to enter the Cash Patient price for all procedure codes. If this is not done, you may see undesired results when using different procedure codes.

 

Other Arrangements: This four-character field can show any special arrangements like student discount, extended payment program, professional discount, or anything else you may need. The code or designation you use is up to you. Data entered in this field displays in the Transaction Entry window as a reminder during the creation of new charges.


Treatment Authorized Through: For easy reference, enter the date through which treatment has been authorized by the patient’s insurance carrier.

Visit Series Information: Many times, insurance carriers will authorize a certain number of visits for a certain type of service. For example, a patient may be eligible for 20 chiropractic visits during a calendar year. When dealing with this type of restriction, you will want to fill out the following fields as described.

Authorization Number: When pre-authorization from the insurance carrier is needed for a series of visits, there may be an authorization number. Enter the authorization number in the Authorization Number field.

Last Visit Date: This is an edit field for making corrections (as needed) to the date of last visit. Each time a visit is recorded in Transaction Entry, this field is updated to match the Date of Service. Click in the field or the down arrow to the right of the field and the calendar opens.

Last Visit Number: The Last Visit Number field tracks how many visits have been entered for this case. This field automatically increments by one when a visit is entered into Transaction Entry. You can also manually manipulate this number from either the case entry window, or from Transaction Entry.

 

Tips and Tricks:
A visit in Transaction Entry is defined as any unique date for which a patient has CHARGES entered. Entering Payments or Adjustments into Transaction Entry will not update the Last Visit Date, or the Last Visit Number.

 

Authorized Number of Visits: Almost any number of visits can be authorized by the insurance carrier in one series. The default is 100. Enter the number of authorized visits in this field. The program reduces the number by one with each visit for medical treatment.

Visit Series ID: A pre-authorized visit series is assigned an ID value. Valid entry is one letter (A-Z) or digit (1-9). Enter the series ID in this field. The default ID is the letter A. When one series of pre-authorized visits is completed, the program automatically moves to the next series (B). You can type a different letter if you want to override the series ID sequence.

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Personal


Case Number: You will not be able to edit the case number field. This field will automatically increment by 1 for each case that is created within your practice. The incrementing is done on a practice level and NOT on a patient level. This means that any case number will only exist once within the practice. This number will be the number used to refer to the case from within Transaction Entry, Deposit Entry, and Office Hours.

Description: The description field is a required field for each Case. You will not be able to save a case without entering in a description. The description should accurately describe the transaction set that will be contained within the case. For example, if you are creating cases on a yearly basis, you would want to assign the year as the case description.

Global Coverage Until: If a Global Surgical Procedure was entered into Transaction Entry for this case, Medisoft will calculate out the number of Global Period days indicated in that procedure’s record and input that expiration date in this field. All transactions entered within this period will default to a zero dollar amount. If the procedure code entered is outside of the global coverage period, the standard charge amount will appear.

Cash Case: If you place a check mark in the field labeled Cash Case, it will be impossible for you to bill any insurance claims for transactions entered into this case. It will prevent all transactions from ever appearing on an insurance aging report. Transactions will immediately appear on a remainder statement without waiting for payment from the insurance carrier. This field should be used ONLY if the patient has no insurance or if the transactions entered into the case will definitely not be covered by an insurance carrier.

Print Patient Statement: If this field is not checked, the charges entered into this case will NEVER appear on a Patient Statement. If you never wish to bill a patient for certain charges, you would want to set up a case this way.

Guarantor: The simplest definition of the Guarantor field is that it defines the person who will receive the patient statement. The drop down menu will give you access to all patients and guarantors that have been entered into the Patient List. This will also be the person listed as the Guarantor for the patient when their Ledger is pulled up within the Quick Ledger.

Marital Status: It is important that you fill out this field to the best of your ability. It is possible that some Electronic Claims will not process properly if this field is not properly filled out.

Student Status: Because most private insurance companies base their coverage for dependants on student status, you will need to enter an appropriate student status for those patients who could be affected by their student status designation. Usually these patients are from 18 to 24 years old.

Employer Information: The employer information is going to automatically populate based on what was entered into the Patient entry screen. Any time a patient changes employers, you should create a new case, and modify the information entered into the Patient entry screen.

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Medisoft Case Setup Overview and Definitions

Medisoft utilizes an accounting system known as Case Based Accounting. Case Based accounting groups transactions together based upon the case they are entered into. Different offices have different methods of using cases. Cases include large portions of the information that will appear on a claim. Within the case, you will assign Insurance Carrier and Guarantor values to transactions. These values will be used to determine how and where claims and statements are sent.

Definition of a Case: A case is a unique condition or situation for which a patient seeks treatment or services. There can be multiple visits for service related to a single case and all services related to that malady or condition are contained in the same case.

There is not one “right” way to create new cases but we will give you a few general guidelines for when to create a new case.

In general, you may need or want to create a new case whenever:

1. The number of transactions entered into that case reaches 650. The transaction limitation includes charges, payments, adjustments, and comments as well as any sub-set of these transaction types.

2. The insurance carrier information for that patient changes. You do not want to simply change the insurance carrier information within the existing case, in order to maintain your record of the patient’s insurance history. The transactions entered into that case under the original insurance carrier should not be associated with a case containing a different insurance carrier.

3. Employer information changes. Within the patient setup, you can set up a default employer for use whenever a new case is created. If a patient changes their employer, generally that change will also include a change in benefits, which will change the insurance carrier associated with them. These changes need to be reflected in a new case.

4. Time period changes. Many offices create a new case for a specific time period. You may want to create a new case for each quarter or for each year. This allows you to group transactions together based on when they occurred. The only limitation you will need to note with this is that payments must be entered into the same case as the charge to which the payment will be applied.

5. Visit based cases. Some offices choose to create a new case for each visit a patient makes to the office. This allows you the most detail in grouping transactions together. However, this option is not necessary if the office uses the Document Number or Serialized Superbill features properly.

6. Variations in the billing process for the same patient. If there are different guarantors for different charges for the same patient, you will need to set up a different case for each guarantor. Similarly, if there are charges that you never wish to bill on a patient statement, those transactions will need to be entered into a separate case.

7. Specialty field changes. There are many specialty fields included within the case screen. Whenever any of these fields change, you will want to create a new case. For example, if the patient was a student, and the student status changes, you will want to create a new case for transactions entered since the student status changed.

8. Global Coverage is used. If a Global Surgical Procedure is entered into Transaction Entry for a case, an automatic calculation is done to determine the end date for that Global Surgery. If more than one Global Surgical Procedure is used for the same case, the Global Coverage Until date will change to the latest date.

There are many other reasons to create new cases. You will need to figure out what works best for your office.

Tips and Tricks:
When browsing through the case screen, you may find that you have fields that are “hidden” without the scroll bar that allows you to access the fields. If documentation such as the Knowledge Base, Help Files, or Training Documentation refers to a field that you cannot see, you may have to expand the size of the case screen in order to make the field visible.

 

You will be able to see some of the Patient demographic information at the bottom of the case window. You will also be able to check the eligibility and print a Face Sheet using the buttons available along the right side of the screen.

If you want to switch your case screen to a different case for that same patient, you can do so using the case field in the lower right corner of the screen.

You may find that the Tab labels are missing from your case screen.

This is due to your display settings being set to use large fonts (large size DPI). In order to correct the issue, you must set your font setting (DPI setting) to Normal.

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