The terms “Managed Care” and “Capitation” plans are interchangeable. Managed Care fee schedules are attached to the Managed Care insurance plans. The fees and their associated plans should be entered prior to entry of patient services.
The fee schedules are divided into two parts – patient amount and insurance amount.
If the patient amount and the insurance amount are both set as $0.00, the procedure is indicated as a covered service and collection of a patient co-pay is not required.
If the patient amount is set as $0.00 and the insurance amount is set as a fee (i.e., $5.00), the procedure is indicated as a covered service where the collection of a patient co-pay is not required. The insurance will provide a supplemental fee payment of $5.00.
If the patient amount is set as a fee (i.e., $5.00) and the insurance amount is set as a fee (i.e., $10.00), the procedure is indicated as a covered service where the collection of a patient co-pay of $5.00 is required. The insurance will provide a supplemental fee payment of $10.00.
If the patient amount is set as a fee (i.e., $5.00) and the insurance amount is set as $0.00, the procedure is indicated as a covered service where the collection of a patient co-pay of $5.00 is required. The insurance will not provide a supplemental fee payment.
If the patient amount and the insurance amount are both set as blank fields, the procedure is indicated as a non-covered service. The patient will be charged the amount indicated on the fee schedule attached to the patient, usually the office default fees.
To recap and illustrate:
|
Pat |
Ins |
Description |
|
0 |
0 |
covered service – patient does not pay an out-of-pocket amount or co-pay |
|
0 |
5 |
covered service – patient pays $0 and insurance pays the office a supplemental amount of $5 |
|
5 |
10 |
covered service – patient pays $5 co-payment to the office, and insurance pays the office $10 supplemental reimbursement |
|
10 |
0 |
covered service – patient pays $10 co-payment to the office, and there is no anticipated supplement insurance reimbursement |
|
Blank |
Blank |
non-covered service – patient will be charged according to the office fee schedule to which the patient is attached (usually office default fees) |