This lesson teaches you how to use the Care Calculator for insurance patients. The Care Calculator takes the patient's primary care plan and creates two financial responsibility forms to help you explain their payment options. The first is for the insurance plan and the second is for the DMPO you use in the clinic. This aids you in explaining cost of care and shows the advantages of using the DMPO.
DMPO = Discount Medical Plan Organization
Creating the Insurance Plan Defaults
Care plans for insurance use specifics on allowed CPT codes and the allowed amounts for those codes. This means that each carrier has its own default care plan.
Care Calculator setup takes time but having good default care plans makes creating care plans for patients quick and easy.
EOB Settings
The Care Calculator uses each carrier's Allowed amount to calculate insurance financial responsibility. The recommended ways to find the correct allowed amounts are:
- Enter amounts shown on the contract with the carrier.
- Auto-populate from History. This function creates an allowed amount based on the average amounts paid by that provider over the past 3 months, as determined by EOB/ERNs entered.
Each patient's Care Calculator uses the default information from the EOB Settings and Insurance Bible tabs for their carrier.
Insurance Bible
Work through these steps for the carriers you plan to use for the Care Calculator. The Care Calculator for each patient starts with the EOB Setting and Insurance Bible defaults created for their carrier. Go to Billing->Carriers to edit the Insurance Bible.
Modify the Global Insurance Bible Template
Creating Patient Care Calculators
The first step in creating a patient's Care Calculator is updating their insurance coverage details. From the patient menu under edit information and insurance tab. The insurance tab has the patient Insurance Information and a Coverage tab.
On the right hand side you will want to include the CPT code level details while on this screen.
If you're calling the carrier to confirm the patient's coverage, open the Coverage Details Tab to access all of the information in one place.
When the patient's insurance information is entered, it's time to create the Care Calculator.
The Care Calculator
You can access the Care Calculator from the menu then Care Calculator button and then from the Edit Information in the Case tab.
The Care Calculator is broken down into four sections:
- Treatment Plan
- Insurance Fees
- Clinic Fees (Cash)
- DMPO fees
Treatment Plan
Enter frequency and duration in the Treatment Plan section. Frequency and duration options are flexible. Hovering over the frequency will give you options for your customized plan. The total number of visits is calculated automatically and populates into other parts of the Care Calculator.
Insurance Fees
Enter quantities for each CPT code in the doctor's treatment plan. Allowable amounts are imported from the carrier's EOB Settings tab. Delete unneeded rows or change allowed amounts, if necessary. If there are missing codes, use the Add Ins. Item button to add them.
Information in the bottom part of this section is automatically entered from the patient's coverage details. This section of the Care Calculator shows what the patient's insurance would pay for the treatment plan.
Clinic Fees (Cash)
Use this section if the patient exceeds insurance limits for any CPT code. Information from this section of the plan is added to the Insurance Financial Responsibility Form.
Search for a CPT code in the search box at the top of the DMPO section. The code is displayed in each section of the Care Calculator.
DMPO
The Care Calculator automatically enters quantities in the DMPO section. Codes in a la Carte Fees come from the DMPO fee schedule. Codes that are not in the fee schedule appear in Excluded DMPO Services.
The bottom part of this section calculates what the patient would pay for their treatment plan if they used the DMPO.
DMPO maximum % and Cap Rate come from the Cash Care Plan template
Create the Financial Responsibility Forms
After you complete the Care Calculator, create the Financial Responsibility forms.
When the forms are created, select each tab and click the button to Print, Email or Send to FileVault the Financial Responsibility forms. If you choose to email the form, a box pops up for you to add the email address.
The Financial Responsibility Form breaks down the patient's care plan for an easy comparison between their insurance and the DMPO.