Entering Billing Rules
Billing Rules are entered by selecting the New Billing Rule (1) button in the Insurance Policy screen. users can edit existing rules by selecting the Edit (3) button.
Once you have clicked on the New Billing Rule button the rules template screen will open, giving the user the option to select a pre-defined rule template or to create a new rule. Once the user has selected the option of his choice the Billing Rule dialogue screen (2) is displayed. The user can modify or make any changes he requires. To edit an existing rule select the edit button.
Rule templates can be created in the Insurance tab of the System Settings.
Rule Types
You can enter in this screen the parameters for the billing rule you wish to create. You have eleven (11) options for various types of billing rules;
1) Policy Pays
2) Policy Price Table
3) Policy Fee Schedule
4) Policy Pays for a Group of Items
5) Policy Pays a Flat Fee for an Invoice
6) Patient Pays
7) Patient Price Table
8) Practice Refunds
9) Practice Writes Off
10) Practice Pays a Service Fee
11) Alert Rule
The examples below are only possible examples of use of the specific rule. They do not reflect all the various possibilities for any given rule. Filopto Billing rules are extremely flexible and can be adapted for other examples than those mentioned below.
Policy Pays: This rule specifies the amount and terms under which the insurance policy will pay a specified amount. Example : The insurance policy will pay a fix amount of $120.00 for a pair of glasses. You can make this rule apply to only certain inventory items by using the Inventory Categories or Groups (see Inventory) so that the rule only applies to specific group of items. Example; you group your lens in a category called Single Vision. You can then apply this rule to the category of items called Single Vision. Categories and Groups can include any number and type of Inventory items. Before making Categories and groups make sure that the ones you will create will meet all your requirements in both insurance rules and inventory reporting and management. Remember that you can also create packages which have categories and groups and which can contain frames, lens, cases etc ... many combinations are available to meet your grouping and sales needs.
Policy Price Table: This rule applies a price, based on a range of values in a user defined price table. Example: the Insurance policy will pay a fix amount of $65.00 for a pair of glasses which retails between $60.00 and $70.00.
Policy Fee Schedule: This rules uses the Medicare fee schedule to determine the price for an item or service. The Medicare fee schedule can be manually entered or uploaded using the Medicare Physician Fee Schedule Payment Amount File National/Carrier available from sources such as your Medicare provider or from the CMS WEB Site (http://www.cms.hhs.gov). Before using this rule make sure you understand how Medicare or other carriers use the Medicare Physician Fee Schedule Payment Amount File National/Carrier file. For additional information see Physician Fee Schedule section below.
Policy Pays for a Group Of Items: This rule applies a price, based on the group of items entered on an invoice. Example: The insurance policy will pay a percentage of service(s), and a pair of single vision glasses. In other words the rule will add together the total fee amounts related to the inventory category single vision for items of the inventory type frame, lens and service(s) and then calculate the percentage the insurance company will pay.
IMPORTANT
If you have entered more than one rule of the type Policy Pays for a Group Of Items with the option "with the following group of items" and items types overlap, the rule reimbursing the patient cost the most, will be the rule used by Filopto and the other rules will be ignored.
For example; you entered a rule for a group of Services and Contacts which reimburses $100.00 . You also entered a rule for a group of Services and Frames which reimburses $120.00. The patient invoice has Services, Frames and Contacts being claimed for insurance purposes. The rule which will be applied is the rule for Services and Frames since it reimburses a larger amount of the patient cost. The rule for Services and Contacts will be ignored. The trigger for this rule is that both rules pay for same services therefore the system must determine which rule to apply. The rule which will be chosen is the rule which reimburses the largest amount of the cost for the patient.
Due to the nature of this insurance rule it can only be applied once all items are added on the invoice. Therefore you will not see this item appear on any line item that you are adding. It will only be calculated at the end, once all items are on the invoice. It will show in the Invoice under the Amount Due from Insurance.
If you have entered a rule of the type Policy Pays for a Group Of Items with the option "for any of the following inventory types", the rule will reimbursing the patient cost up to the maximum specified and stop for any combination of items included in the group listed. For example: you have a frame, exam and other materials. Filopto will add the cost, up to the maximum amount specified and stop. If no maximum is specified all items in the list will be added up and attributed as specified to the insurance policy.
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Policy Pays a Flat Fee for an Invoice: This rule applies a price based on the total amount of an invoice. Example: the insurance policy pays a flat fee of $100 for all optical services including item dispensed. The rule will add up the invoice items being claimed for insurance payment and apply 100% of the amount up to $100.00. You can change the % covered based on the policy, for example the insurance policy may pay 80% of the invoice up to a maximum of $100.00.
IMPORTANT
Due to the nature of the Policy Pays a Flat Fee for an Invoice rule, it can only be applied once all invoice items are added to the invoice. Therefore when you add items to an invoice and mark it for insurance claim, you will not see the insurance amount due for this rule applied to any line item. It will appear on the invoice as an amount due from the insurance policy.
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Patient Pays: This rule defines the amount the patient must pay. Example: the Insurance policy requires a $20.00 co-pay. The Patient Pays $20.00.
Another example is that you have a policy that states : Policy pays a maximum of $100 for Services and Frames (see Policy Pays for a Group of Items) and the patient pays the balance, but must receives a 20% discount on the balance. The 20 % discount must be written off by the practice ( see rule Practice write-off) .
The Patient Pays rule is that the Patient is responsible for 80% of the balance once the insurance has paid their share. By using the " Balance after Policy Pays " option and setting the amount to 80% will meet this policy requirement of the patient pays portion of the invoice.
Patient Price Table: This rule provides for a patient to pay a set sum, based on a Price table. Example: The Insurance policy states that the patient must pay $45.00 for a pair of Glasses which retails between $120.00 and $145.00.
Practice Refunds: This rules stipulates what amount and to whom the practice must refund a specified amount. This rules sets up an Accounts Payable entry in Filopto. Example: The insurance policy states that the practice must pay a refund of $20.00 to the patient .
Practice Write Off: This rule stipulates what amount needs to be automatically written off.. Example: the insurance policy states that it will pay $80.00 of your $100.00 bill and that the remaining unpaid $20.00 cannot be transferred to a patient, but must be written off. The rule will automatically create the accounting entry to write off the remaining $20.00. Another example is when a policy states that the balance not transferred to the patient must be written off, then you can use the option " the Balance" which will write off any remaining amount.
Practice pays a Service Fee: The rule creates an Accounts Payable entry showing the amount of the service fee to be paid and to whom. This service fee has no effect on a claim or patient invoice. Example: The insurance policy states that for each patient visit using this policy, the practice must remit a usage fee of $20.00 to the Insurance carrier. The rule will create an Accounts Payable to the insurance carrier for $20.00. This Accounts Payable amount has no effect on the Claim or the Patient Invoice.
Alert Rule: The Alert Rule is similar to the warning rule used in Filopto. It will display a custom message at the times defined to alert a user that the Patient is using this specific insurance policy and that special actions need to be taken. Example you have an insurance policy which requires several factors which cannot be predicted to be considered each time before a fee can be claimed. In this instance, human intervention is required. The Alert rule can notify the user of the special nature of this policy and they can manually calculate the fee that should be charged.
To create a billing rule, the following fields must be completed. You can only create one rule at a time. Select the Rule type and then enter the information related to that rule. Once you have defined the rule, close the rule screen to save the rule (click the OK button) .
Name of Rule : enter a descriptive name for your rule
Rule Author : Automatically completed to identify who created the rule
Effective Date: Date the rule will start to be valid. Must have a date for it to be used.
Rule Status: Active or Non-Active. Only Active Rules are used by Filopto. Rules cannot be deleted only rendered non-active.
Discontinued By: The name of the user which discontinued the rule
Expiry Date: Date the rule will be discontinued.
Rule Description: A description of what the rule is used for and why it was created. We recommend that you provide a description so to know what the rule is supposed to do.
Applicable on to Alert Billing Rule:
Show at Invoice Time
Show at Exam Time The time when the rule is to be triggered (displayed or applied).
The Rule : The next set of fields are the fields that must be completed to create the rule. The fields are specific to the type of rule being created. Insure that all applicable fields are properly completed and test with the rule tester that the rule is activated at the appropriate times.
