Patient Responsibility Estimator Criteria

As more information is entered into the Estimator, the higher the potential confidence level for the Estimate.

• Patient/DOS

• A Patient and DOS are required to evaluate Estimation.
• This will be used to auto-populate (if applicable) the Policy information, Recent Eligibility, and Benefits in the Policy & Out-of-Pocket section.

• Policy

• This section will populate benefits from the Patient selected.

• The Policy can be changed to a different Insurance Policy.

• Eligibility can be checked.
• Eligibility information displays from the most recent Eligibility check
• Access to Insurance Management.

• Out-of-Pocket

• Based on the selected Network (In-Network or Out-of-Network), Service Type, and Place of Service, applicable out-of-pocket expenses such as Copays, Coinsurance, and Deductibles will be displayed.

• The Estimate updates dynamically to reflect the selected Copay or Coinsurance type.

• Copay and Coinsurance amounts specific to the selected service represent fixed fees or percentage-based costs that the Patient is responsible for.

• Total annual Deductible and remaining Deductible amounts for both individual and family plans indicate amounts that must be met before insurance coverage applies.

• Out-of-pocket maximums and remaining balances reflect the limit on total Patient expenses before full insurance coverage begins.

• Users can toggle between different benefit types, such as office visits, inpatient care, or mental health services, to see how patient financial responsibility varies.

• Deductible

•  Displays only the remaining deductible for Patient Estimation from the two responses we get: "Service Year" or "Remaining".

• Procedures

• Enter Procedures and additional criteria to determine the Allowed Amounts.

• If available in an Allowed Fee Schedule, that amount will be used.
• Otherwise the Allowed Fee Algorithm (below) will be used.
• If an Allowed Fee cannot be identified, it will need to be manually entered.
• Use the "From Previous Service" link.
• Use the "From Previous Estimate" link.

• Previous Estimates created for this Patient can be viewed.

• Using the Facility and Billing filters will help further determine an Allowed Fee.
• A Discount based on a Percentage or Flat amount can be entered.

• Save

• When an Estimate is Saved, it will be stored in the Patient Estimate History.
• Save/Print can be used to Print the Estimate during Estimation.

• Charge Amount & Allowed Amount

• If a Modifier is entered in the Modifier field, and there is a Modifier Rule, both the Charge and the Allowed amounts are affected by the Modifier rule. (Libraries > Modifiers)

Estimate History

Patient Estimate History: Accessible from the Patient Dashboard.

• In the Active Policies panel on the Patient Dashboard, select the Estimate History link. 

History of Estimates for all Patients

• To view the history of Estimates for all patients, from Admin on the Left Side Menu, select the Patient Estimate History button.

Allowed Fee Algorithm

• Confidence Scale: 100

• Same Patient
• Same CPT® Code
• Same Insurance
• Same POS
• Same Provider

• Confidence Scale: 95

• Same CPT Code
• Same Insurance
• Same POS
• Same Provider
• < 3 months (median if > 10 records)

• Confidence Scale: 90

• Same CPT Code
• Same Insurance
• Same POS
• Same Provider
• < 6 months (median if > 10 records)

• Confidence Scale: 90

• Allowed fee schedule

• Confidence Scale: 85

• Same CPT Code
• Same Insurance
• Same POS
• Same Provider
• < 12 months (median if > 10 records)

• Confidence Scale: 70

• Same CPT Code
• Same POS
• Same Provider
• < 3 months (median if > 10 records)

• Confidence Scale: 60

• Same CPT Code
• Same POS
• Same Provider
• < 6 months (median if > 10 records)

• Confidence Scale: 50

• Same CPT Code
• Same POS
• Same Provider
• < 12 months (median if > 10 records)

• Confidence Scale: 40

• Else -> Editable

Confidence Algorithm

• Confidence Scale: 100

• If the Deductible is available from Eligibility

• Confidence Scale: 0

• If no Deductible information is available

Calculation

• (Deductible * .6) + (Allowed (from Allowed Fee Algorithm) * .4) = Score
• The calculated score is compared to the scale below to display a Confidence Level.

The Allowed Fee Schedule is the first value, then a check for prior previous postings to ascertain the Confidence Level.

Confidence Scale

• 0 - 20 = NONE
• 21 - 40 = VERY LOW
• 41 - 60 = LOW
• 61 - 80 = MODERATE
• 81 - 99 = HIGH
• 100 = VERY HIGH