Patient Responsibility Estimator Criteria
As more information is entered into the Estimator, the higher the potential confidence level for the Estimate.
- 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.
- 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.
- 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.
- Displays only the remaining deductible for Patient Estimation from the two responses we get: "Service Year" or "Remaining".
- 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.
- 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
- Same Patient
- Same CPT® Code
- Same Insurance
- Same POS
- Same Provider
- Same CPT Code
- Same Insurance
- Same POS
- Same Provider
- < 3 months (median if > 10 records)
- Same CPT Code
- Same Insurance
- Same POS
- Same Provider
- < 6 months (median if > 10 records)
- Same CPT Code
- Same Insurance
- Same POS
- Same Provider
- < 12 months (median if > 10 records)
- Same CPT Code
- Same POS
- Same Provider
- < 3 months (median if > 10 records)
- Same CPT Code
- Same POS
- Same Provider
- < 6 months (median if > 10 records)
- Same CPT Code
- Same POS
- Same Provider
- < 12 months (median if > 10 records)
Confidence Algorithm
- If the Deductible is available from Eligibility
- 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