Billing Rules Overview
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Summary
The program is a "rules driven" system. That means that when setting up the overall system, companies, carriers, etc., you enter information that controls how different items get billed. When information about visits is entered in the clinic the user needs know very little about billing- the program handles it automatically by following the billing rules entered during setup.
Activity can be billed to one of three payer types: the employer, an insurance carrier, or the patient. " Employer services" are almost always paid for by the employer, but in certain circumstances, they might be covered by the employee/patient. In some cases, an employer might have invoices for Employer Services sent to a TPA Third Party Administrator who administers a Work Comp insurance plan for a self-insured employer; not to be confused with a Contract TPA, which refers to a third party that administers drug screening on behalf of an employer. While workers' comp visits are typically guaranteed by a carrier An insurance company that pays for Workers' Comp or Private Practice bills., some employers are self-insured and will pay directly. Most Urgent Care visits are paid by a group insurance carrier, but some may be paid by the patient.
Several "billing entities" other than employers and insurance carriers can be entered in the program. These include managed care organizations (MCOs), contract labs for drug screens, and contract TPAs for drug screen collections. Each payer entity, except patients, has a related billing account. The billing account carries the receivables, outstanding, that is, unpaid invoices and might or might not have the same name, address, and other identifying information as the company, carrier, etc. Multiple companies can have the same billing account, as is the case with franchise operations.
The program supports split-billing and alternate bill-to addresses . A split bill occurs when part of a bill is paid by one account and the rest by another account. That is to say, the services are paid for by completely different parties. The most common example of split billing is when a drug screen is entered on a Workers' Comp visit, but split off during invoicing to be paid for by the employer instead of the insurance carrier. Split billing can be set up on a company protocol or with a services contract.
Alternate bill-to addressing occurs entirely within a single billing account. This feature allows the program to take certain visits or certain billable activities and produce them on a separate invoice. The rest of the charges for the account will go on the primary invoice going to the billing account's main address. The indicated charges will be placed on a separate invoice. (In spite of the name, "alternate bill-to address", the invoice might or might not go to a different contact or address).
Separate fee schedules are available for Employer Services, Workers' Comp, and Private Practice billing. If a clinic's service area spans a state border, you can create state fee schedules so that Workers' Comp invoicing can use the appropriate fees for each state. Separate fee schedules can also be entered for each clinic in a multi-clinic enterprise. Special services contract pricing and a special Medicare fee schedule are also available.
Special pricing can be provided to billing accounts in several ways. An across the board discount or premium can be applied. Special override fees can be entered for specified medical activities. Special fees can be entered for activities on a specific type of visit. And contracts with third party payers can be entered.