Estimator Criteria and Calculations

Estimator Criteria and Calculations


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 Policy's Benefits, the Copay Types, Co-Insurance Types, Copay Amount, Co-Insurance, Individual & Family Deductibles, and amount remaining will be displayed.
  • Toggle between In-Network and Out-of-Network benefits.
  • The Copay/Co-Insurance Type selected will be reflected in the Estimate.
  • 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



CPT® copyright 2019 American Medical Association. All rights reserved.

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