Insurance Tracking

The system is designed to track procedures through the insurance process. There are three significant stages:

  1. Performed but UNSUBMITTED.
  2. Filed and OUTSTANDING.
  3. Insurance PAID, balance due by patient.

Even if you do not take advantage of the tracking for your own purposes, it is important to maintain proper tracking. The stage of the tracking process can affect the service charges calculated by the system and the amount due printed on the patient billing statements.

Unsubmitted claims:

  1. Produce an insurance claim when you print batch insurance.
  2. Produce an insurance claim when you enter I at the procedure code prompt at the Family Ledger.
  3. Are excluded from service charge calculations if you request.

Outstanding claims:

  1. Are excluded from billing statements if you request.
  2. Are excluded from service charge calculations if you request.

You do not have to do anything special for insurance tracking; the system handles it internally:

  1. When you enter a procedure for a patient who has an insurance carrier defined on his record, the system marks the procedure Unsubmitted.
  2. The procedure remains unsubmitted until you produce a claim. As the claim is produced, the system marks the procedure Outstanding.
  3. When you receive insurance payment or notice of denial and you enter the appropriate procedure code on the patient's ledger (15=Insurance Payment, 16=Insurance Denied), the system displays the insurance disposal window. The insurance disposal window lists all the unsubmitted or outstanding procedures for the patient.

    Right-click the procedures for which you have received a response from the insurance company and mark them disposed.

    NOTE: If none of the procedures are still outstanding for insurance payment, click Dispose All to mark them all disposed instead of deleting them one at a time.

    If the patient has only one insurance carrier, the insurance tracking process is complete and the patient owes the remaining balance. If the patient has dual insurance coverage, the system marks the procedures as Unsubmitted to the secondary carrier.

  4. The procedure remains unsubmitted to the secondary carrier until you produce another claim. As the claim is produced, the system marks the procedure Outstanding to the secondary carrier.
  5. When you receive insurance payment or denial and mark the procedures as disposed, the insurance tracking process is complete.

NOTE: If the patient has dual coverage but the primary carrier pays 100% on a procedure, right-click it and choose Dispose to mark it disposed for both the primary and secondary coverage.

There is one exception to this insurance tracking process. When you produce a claim, if the Assignment setting on the patient's Employer record is set to No (to indicate insurance payment should go directly to the patient), the system will automatically mark the procedure Disposed instead of marking it as Outstanding. Since the procedure is disposed, the system will consider the balance immediately due by the patient.

Maintaining Proper Tracking
Although the system handles insurance tracking internally, circumstances may arise where you need to manually change the insurance status of a procedure.
To Manually Change The Insurance Status:
  1. Select Family Ledger at the Transactions Menu.
  2. Select the desired patient.
  3. Right-click on any procedure to make desired changes.
  4. If the system prompts for your password, enter it.
  5. While in edit mode, you can choose any of the options displayed in the box to change the insurance status of the highlighted procedure.

To mark procedures disposed for a patient, you may find it more efficient to:

  1. Select Family Ledger at the Transactions Menu.
  2. Select the desired patient.
  3. When the ledger is displayed, press Tab to accept the practitioner number as it is displayed.
  4. Enter procedure code 15 (Insurance Payment) at the procedure code prompt.
  5. Enter 0.00 for the dollar amount. The insurance disposal window is displayed on the screen.
  6. Mark the desired procedures disposed.

An insurance payment with a 0.00 dollar amount will not be written to the patient's ledger. This eliminates the potential source of confusion.

To mark ALL unsubmitted procedures between a range of dates as filed, use the Mark Procedures Filed utility.

To remove ALL procedures between a range of dates from tracking, use the Remove Procedures From Tracking utility.

Disabling Insurance Tracking
You should not disable insurance tracking unless you want to enter insurance data for a patient but never want to produce an insurance claim and never expect insurance co-payment.

Example: Plans are available to patients where the insurance company doesn't make any co-payment. Belonging to the plan simply qualifies the patient for discounted pricing.

If you have patients on such a plan and have purchased the Unlimited Fee Schedule capability, you can create an insurance plan that has a fee schedule reflecting this special pricing. You can then define on the patient record that he has this plan. Therefore, when entering procedures for the patient, the charges will automatically default to this special pricing.

However, since you will not be printing an insurance claim, the system will erroneously reflect the procedures are unsubmitted and need to be filed for insurance payment.

To disable the insurance tracking, go to the patient insurance information screen and enter *** as the Insured ID#. Procedures that are entered for a patient that has three asterisks in their Insured ID# field will not be put into insurance tracking (just like a patient that doesn't have insurance).

Checking Insurance Tracking
You can check the insurance tracking status of the procedures in your system using the following reports.

Unsubmitted Claims Report: Lists ALL procedures in the system still unsubmitted for insurance payment. If you run Batch Claims, an insurance claim prints for each patient on this list.

Outstanding Claims Report: Lists procedures that have been filed but are still outstanding for a response from the carrier.

Daysheet: The far right column of this report indicates the insurance status of procedures entered for the day. If you run this at the end of each day, it brings to your attention any procedures you may have failed to file.

Family Ledger Report: The far right column of this report indicates the insurance status of procedures entered for the family.