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)

Confidence Score

The Confidence Score tells you how reliable a Patient Responsibility Estimate is. There are two types of Confidence Scores:

• Procedure-Level Confidence: Reflects how reliable the Allowed Amount is for a single Procedure.
• Overall (Estimate-Level) Confidence: Reflects how reliable the entire estimate is, including the Patient's out-of-pocket responsibility.

• This combines Procedure-Level Confidence with valid deductible information (if it was returned from Eligibility).

• A Procedure with 100% Procedure Confidence will still produce a low Overall Confidence if Eligibility was not run.

The Confidence Score tells you how reliable a patient responsibility estimate is. It is displayed as a labeled rating with a color to make it easy to assess at a glance.

Procedure-Level Confidence Calculation

Allowed Fees are the foundation of the Procedure-Level Confidence Calculation.

• When you add a Procedure to an Estimate, the System automatically tries to find the most accurate Allowed amount. 

• The source it lands on determines the confidence score for that procedure line.
• This confidence score is then skewed based on the number of Payments found within a specified timeframe.

• The System checks sources in the following order and stops as soon as it finds a usable amount:

1. Fee Schedule (Confidence: 100)

• The System first checks for an Allowed Fee Schedule for the Payer.

• If one exists, it is used immediately and is dependent on the correct Insurance being selected on the Estimate.

2. Patient History with the Payer (Confidence: 100)

• If no Fee Schedule exists, the System looks for a prior Claim where the Patient has had the same Procedure paid for by the exact Insurance with the same Provider and Facility within the last 6 months.

• Since this is a Patient-specific match, it is equally reliable as a Fee Schedule.

3. Other Patients, Same Payer (Confidence: 80-95)

• If no Patient-specific match is found, the System widens the search to all Patients who had this Procedure paid by the same Insurance with the same Provider and Facility.

• The number of Payments and their recency will also contribute to the Confidence Score.

• The System starts by looking at the most recent month of Payments.

• If it finds 10 or more, it uses them. If not, it looks back 3 months.
• This process is repeated until 6 months back.

4. Other Patients, Any Payer (Confidence: 40-70)

• If the Patient's Insurance has no Payment history, the System looks at what any Insurance has paid for this Procedure at the same Provider and Facility.

• This is a last resort since different Insurances negotiate different rates.
• The number of Payments and their recency will also contribute to the Confidence Score.
• The System starts by looking at the most recent month of Payments.

• If it finds 10 or more, it uses them. If not, it looks back 3 months.
• This process is repeated until 6 months back.

5. No Data Found (Confidence: 40, manual entry required)

• If nothing is found at any step, the Allowed Fee field is left blank for manual entry and the Confidence Score defaults to 40.

Overall Confidence Score Calculation

The Overall Confidence Score combines two weighted components:

• Deductible Component (61% weight)

• If deductible information is available from Eligibility (or the patient is Self Pay): contributes 61 points
• If no deductible information is available: contributes 0 points

• Allowed Fee Component (39% weight)

• The average confidence score across all procedure lines on the estimate, multiplied by 0.39
• Note: This is only applicable if at least one Procedure has a Confidence Score.

Formula: (Deductible Component) + (Average Procedure Confidence × 0.39) = Overall Score

Examples:

• Deductible available + all procedures at confidence 100 = 61 + 39 = 100 (VERY HIGH)
• No deductible + all procedures at confidence 80 = 0 + 31.2 = 31 (VERY LOW)

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.