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Help with calculating coinsurance, pt portion and percentages

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  • Carol Roush
    Hello Everyone :) Soooo, with my new job, I m learning I m the one that inserts the DOS, procedure code, amount billed (fee schedule), insurance contracted
    Message 1 of 9 , Jul 12, 2008
    • 0 Attachment
      Hello Everyone :)

      Soooo, with my new job, I'm learning I'm the one that inserts the DOS, procedure code, amount billed (fee schedule), insurance contracted rate, patient portion and co-insurance amount in the Excel spreadsheet. This is how my supervisor/owner of the business does the billing.

      I'm slowly learning how to figure out what the co-ins which is the contracted rate x the percentage of what the pt pays.

      I also learned that 100% of the contracted rate is the pt portion until the deductible is met. When my supervisor went over all the information she did with me, it went over my head a bit. I had never learned this in class. Well, not these calculations.

      I still have to learn how to find out what was met and figure out remaining visits and such. Still not clear about it. I thought the accountant/biller

      Everyone knows what I'm talking about? if you have any other calculation formulas to share with me to help me out at my job with insurance....please let me know! It's greatly appreciated!

      Thanks!,

      Carol
    • Lin
      Hmm.. Coinsurance is simply A PORTION of the patient s cost sharing in the
      Message 2 of 9 , Jul 12, 2008
      • 0 Attachment
        Hmm..

        << the co-ins which is the contracted rate x the percentage of what the pt
        pays.>>



        Coinsurance is simply A PORTION of the patient's cost sharing in the plan.
        For example if a plan pays 80% of U&C the patient's out of pocket is 20%
        plus any amount over U&C. If it's a plan the provider participates with, the
        patient then pays their copay and is not responsible for the difference
        between the allowed amount and billed amount.



        << I also learned that 100% of the contracted rate is the pt portion until
        the deductible is met.>>



        Yes, that's correct if the patient has a deductible to meet, they are
        responsible for full payment until their deductible is met. Depending on
        how the office does benefit verifications, this is something that can be
        found out by verifying benefits and documenting the phone call. A scenario
        might go like this: The office calls the carrier and inquires about
        benefits, the rep says the patient has a $200 deductible which HAS not been
        met as of that date. Depending on the practices office policy they can opt
        to bill the patient later for the amount going towards deductible or they
        can request the fee at the time of service. The rep can only tell you a
        deductible has or has not been met as of that date. With Medicare for
        example a deductible is often met within a visit or two the rep might even
        be able to tell you there are XX amount of claims in the system which HAVE
        NOT been processed which basically hints to you that by the time your claim
        is processed the deductible will have been met.

        When I worked as a claims examiner we were trained to never give out the
        dollar amount of the deductible yet to be reached, the reason was simply
        that it could cause a provider to bill "according to that amount needed"
        which was considered to be fraud. Likewise it's the same reason the rep
        cannot give out U&C amounts over the phone.



        It sounds like you are mostly dealing with indemnity plans? As there is a
        whole other world with PPO's HMO's etc.





        Linda Walker

        Practice Managers Resource & Networking Community
        <http://www.billerswebsite.com> http://www.billerswebsite.com
        A division of K&L Media, LLC
        <http://www.klmediallc.com> http://www.klmediallc.com

        Website Design & Management for the Medical Services Industry









        From: MedicalBillers@yahoogroups.com [mailto:MedicalBillers@yahoogroups.com]
        On Behalf Of Carol Roush
        Sent: Saturday, July 12, 2008 9:58 AM
        To: MedicalBillers@yahoogroups.com
        Subject: [MedicalBillers] Help with calculating coinsurance, pt portion and
        percentages



        Hello Everyone :)

        Soooo, with my new job, I'm learning I'm the one that inserts the DOS,
        procedure code, amount billed (fee schedule), insurance contracted rate,
        patient portion and co-insurance amount in the Excel spreadsheet. This is
        how my supervisor/owner of the business does the billing.

        I'm slowly learning how to figure out what the co-ins which is the
        contracted rate x the percentage of what the pt pays.

        I also learned that 100% of the contracted rate is the pt portion until the
        deductible is met. When my supervisor went over all the information she did
        with me, it went over my head a bit. I had never learned this in class.
        Well, not these calculations.

        I still have to learn how to find out what was met and figure out remaining
        visits and such. Still not clear about it. I thought the accountant/biller

        Everyone knows what I'm talking about? if you have any other calculation
        formulas to share with me to help me out at my job with insurance....please
        let me know! It's greatly appreciated!

        Thanks!,

        Carol





        [Non-text portions of this message have been removed]
      • kishore kumar
        Heyy... Linda, Marvelous Job Buddyy...!!! keep it up..!! Regards, Kishore KK, IRS specialist, Idaho. ... From: Lin Subject: RE:
        Message 3 of 9 , Jul 12, 2008
        • 0 Attachment
          Heyy... Linda,

          Marvelous Job Buddyy...!!! keep it up..!!

          Regards,
          Kishore KK,
          IRS specialist, Idaho.

          --- On Sat, 7/12/08, Lin <italiandoll1967@...> wrote:
          From: Lin <italiandoll1967@...>
          Subject: RE: [MedicalBillers] Help with calculating coinsurance, pt portion and percentages
          To: MedicalBillers@yahoogroups.com
          Date: Saturday, July 12, 2008, 8:33 PM











          Hmm..



          << the co-ins which is the contracted rate x the percentage of what the pt

          pays.>>



          Coinsurance is simply A PORTION of the patient's cost sharing in the plan.

          For example if a plan pays 80% of U&C the patient's out of pocket is 20%

          plus any amount over U&C. If it's a plan the provider participates with, the

          patient then pays their copay and is not responsible for the difference

          between the allowed amount and billed amount.



          << I also learned that 100% of the contracted rate is the pt portion until

          the deductible is met.>>



          Yes, that's correct if the patient has a deductible to meet, they are

          responsible for full payment until their deductible is met. Depending on

          how the office does benefit verifications, this is something that can be

          found out by verifying benefits and documenting the phone call. A scenario

          might go like this: The office calls the carrier and inquires about

          benefits, the rep says the patient has a $200 deductible which HAS not been

          met as of that date. Depending on the practices office policy they can opt

          to bill the patient later for the amount going towards deductible or they

          can request the fee at the time of service. The rep can only tell you a

          deductible has or has not been met as of that date. With Medicare for

          example a deductible is often met within a visit or two the rep might even

          be able to tell you there are XX amount of claims in the system which HAVE

          NOT been processed which basically hints to you that by the time your claim

          is processed the deductible will have been met.



          When I worked as a claims examiner we were trained to never give out the

          dollar amount of the deductible yet to be reached, the reason was simply

          that it could cause a provider to bill "according to that amount needed"

          which was considered to be fraud. Likewise it's the same reason the rep

          cannot give out U&C amounts over the phone.



          It sounds like you are mostly dealing with indemnity plans? As there is a

          whole other world with PPO's HMO's etc.



          Linda Walker



          Practice Managers Resource & Networking Community

          <http://www.billersw ebsite.com> http://www.billersw ebsite.com

          A division of K&L Media, LLC

          <http://www.klmedial lc.com> http://www.klmedial lc.com



          Website Design & Management for the Medical Services Industry



          From: MedicalBillers@ yahoogroups. com [mailto:MedicalBillers@ yahoogroups. com]

          On Behalf Of Carol Roush

          Sent: Saturday, July 12, 2008 9:58 AM

          To: MedicalBillers@ yahoogroups. com

          Subject: [MedicalBillers] Help with calculating coinsurance, pt portion and

          percentages



          Hello Everyone :)



          Soooo, with my new job, I'm learning I'm the one that inserts the DOS,

          procedure code, amount billed (fee schedule), insurance contracted rate,

          patient portion and co-insurance amount in the Excel spreadsheet. This is

          how my supervisor/owner of the business does the billing.



          I'm slowly learning how to figure out what the co-ins which is the

          contracted rate x the percentage of what the pt pays.



          I also learned that 100% of the contracted rate is the pt portion until the

          deductible is met. When my supervisor went over all the information she did

          with me, it went over my head a bit. I had never learned this in class.

          Well, not these calculations.



          I still have to learn how to find out what was met and figure out remaining

          visits and such. Still not clear about it. I thought the accountant/biller



          Everyone knows what I'm talking about? if you have any other calculation

          formulas to share with me to help me out at my job with insurance... .please

          let me know! It's greatly appreciated!



          Thanks!,



          Carol



          [Non-text portions of this message have been removed]





























          [Non-text portions of this message have been removed]
        • Carol Roush
          Linda, I m dealing with Aetna, Blue Cross, Blue Shield, Great West, IPA s, Kaiser. Those are just a few that I can recall right now. Carol
          Message 4 of 9 , Jul 12, 2008
          • 0 Attachment
            Linda,

            I'm dealing with Aetna, Blue Cross, Blue Shield, Great West, IPA's, Kaiser. Those are just a few that I can recall right now.

            Carol


            --- On Sat, 7/12/08, Lin <italiandoll1967@...> wrote:

            > From: Lin <italiandoll1967@...>
            > Subject: RE: [MedicalBillers] Help with calculating coinsurance, pt portion and percentages
            > To: MedicalBillers@yahoogroups.com
            > Date: Saturday, July 12, 2008, 3:03 PM
            > Hmm..
            >
            > << the co-ins which is the contracted rate x the
            > percentage of what the pt
            > pays.>>
            >
            >
            >
            > Coinsurance is simply A PORTION of the patient's cost
            > sharing in the plan.
            > For example if a plan pays 80% of U&C the patient's
            > out of pocket is 20%
            > plus any amount over U&C. If it's a plan the
            > provider participates with, the
            > patient then pays their copay and is not responsible for
            > the difference
            > between the allowed amount and billed amount.
            >
            >
            >
            > << I also learned that 100% of the contracted rate is
            > the pt portion until
            > the deductible is met.>>
            >
            >
            >
            > Yes, that's correct if the patient has a deductible to
            > meet, they are
            > responsible for full payment until their deductible is met.
            > Depending on
            > how the office does benefit verifications, this is
            > something that can be
            > found out by verifying benefits and documenting the phone
            > call. A scenario
            > might go like this: The office calls the carrier and
            > inquires about
            > benefits, the rep says the patient has a $200 deductible
            > which HAS not been
            > met as of that date. Depending on the practices office
            > policy they can opt
            > to bill the patient later for the amount going towards
            > deductible or they
            > can request the fee at the time of service. The rep can
            > only tell you a
            > deductible has or has not been met as of that date. With
            > Medicare for
            > example a deductible is often met within a visit or two the
            > rep might even
            > be able to tell you there are XX amount of claims in the
            > system which HAVE
            > NOT been processed which basically hints to you that by the
            > time your claim
            > is processed the deductible will have been met.
            >
            > When I worked as a claims examiner we were trained to never
            > give out the
            > dollar amount of the deductible yet to be reached, the
            > reason was simply
            > that it could cause a provider to bill "according to
            > that amount needed"
            > which was considered to be fraud. Likewise it's the
            > same reason the rep
            > cannot give out U&C amounts over the phone.
            >
            >
            >
            > It sounds like you are mostly dealing with indemnity plans?
            > As there is a
            > whole other world with PPO's HMO's etc.
            >
            >
            >
            >
            >
            > Linda Walker
            >
            > Practice Managers Resource & Networking Community
            > <http://www.billerswebsite.com>
            > http://www.billerswebsite.com
            > A division of K&L Media, LLC
            > <http://www.klmediallc.com>
            > http://www.klmediallc.com
            >
            > Website Design & Management for the Medical Services
            > Industry
            >
            >
            >
            >
            >
            >
            >
            >
            >
            > From: MedicalBillers@yahoogroups.com
            > [mailto:MedicalBillers@yahoogroups.com]
            > On Behalf Of Carol Roush
            > Sent: Saturday, July 12, 2008 9:58 AM
            > To: MedicalBillers@yahoogroups.com
            > Subject: [MedicalBillers] Help with calculating
            > coinsurance, pt portion and
            > percentages
            >
            >
            >
            > Hello Everyone :)
            >
            > Soooo, with my new job, I'm learning I'm the one
            > that inserts the DOS,
            > procedure code, amount billed (fee schedule), insurance
            > contracted rate,
            > patient portion and co-insurance amount in the Excel
            > spreadsheet. This is
            > how my supervisor/owner of the business does the billing.
            >
            > I'm slowly learning how to figure out what the co-ins
            > which is the
            > contracted rate x the percentage of what the pt pays.
            >
            > I also learned that 100% of the contracted rate is the pt
            > portion until the
            > deductible is met. When my supervisor went over all the
            > information she did
            > with me, it went over my head a bit. I had never learned
            > this in class.
            > Well, not these calculations.
            >
            > I still have to learn how to find out what was met and
            > figure out remaining
            > visits and such. Still not clear about it. I thought the
            > accountant/biller
            >
            > Everyone knows what I'm talking about? if you have any
            > other calculation
            > formulas to share with me to help me out at my job with
            > insurance....please
            > let me know! It's greatly appreciated!
            >
            > Thanks!,
            >
            > Carol
            >
            >
            >
            >
            >
            > [Non-text portions of this message have been removed]
          • Lin
            Right, but along with the different carriers, there are different types of policies, most carriers have both managed care plans and indemnity plans. Linda
            Message 5 of 9 , Jul 12, 2008
            • 0 Attachment
              Right, but along with the different carriers, there are different types of
              policies, most carriers have both managed care plans and indemnity plans.





              Linda Walker

              Practice Managers Resource & Networking Community
              <http://www.billerswebsite.com> http://www.billerswebsite.com
              A division of K&L Media, LLC
              <http://www.klmediallc.com> http://www.klmediallc.com

              Website Design & Management for the Medical Services Industry







              From: MedicalBillers@yahoogroups.com [mailto:MedicalBillers@yahoogroups.com]
              On Behalf Of Carol Roush
              Sent: Saturday, July 12, 2008 11:18 AM
              To: MedicalBillers@yahoogroups.com
              Subject: [MedicalBillers] Linda



              Linda,

              I'm dealing with Aetna, Blue Cross, Blue Shield, Great West, IPA's, Kaiser.
              Those are just a few that I can recall right now.

              Carol

              --- On Sat, 7/12/08, Lin <italiandoll1967@...
              <mailto:italiandoll1967%40yahoo.com> > wrote:

              > From: Lin <italiandoll1967@... <mailto:italiandoll1967%40yahoo.com>
              >
              > Subject: RE: [MedicalBillers] Help with calculating coinsurance, pt
              portion and percentages
              > To: MedicalBillers@yahoogroups.com
              <mailto:MedicalBillers%40yahoogroups.com>
              > Date: Saturday, July 12, 2008, 3:03 PM
              > Hmm..
              >
              > << the co-ins which is the contracted rate x the
              > percentage of what the pt
              > pays.>>
              >
              >
              >
              > Coinsurance is simply A PORTION of the patient's cost
              > sharing in the plan.
              > For example if a plan pays 80% of U&C the patient's
              > out of pocket is 20%
              > plus any amount over U&C. If it's a plan the
              > provider participates with, the
              > patient then pays their copay and is not responsible for
              > the difference
              > between the allowed amount and billed amount.
              >
              >
              >
              > << I also learned that 100% of the contracted rate is
              > the pt portion until
              > the deductible is met.>>
              >
              >
              >
              > Yes, that's correct if the patient has a deductible to
              > meet, they are
              > responsible for full payment until their deductible is met.
              > Depending on
              > how the office does benefit verifications, this is
              > something that can be
              > found out by verifying benefits and documenting the phone
              > call. A scenario
              > might go like this: The office calls the carrier and
              > inquires about
              > benefits, the rep says the patient has a $200 deductible
              > which HAS not been
              > met as of that date. Depending on the practices office
              > policy they can opt
              > to bill the patient later for the amount going towards
              > deductible or they
              > can request the fee at the time of service. The rep can
              > only tell you a
              > deductible has or has not been met as of that date. With
              > Medicare for
              > example a deductible is often met within a visit or two the
              > rep might even
              > be able to tell you there are XX amount of claims in the
              > system which HAVE
              > NOT been processed which basically hints to you that by the
              > time your claim
              > is processed the deductible will have been met.
              >
              > When I worked as a claims examiner we were trained to never
              > give out the
              > dollar amount of the deductible yet to be reached, the
              > reason was simply
              > that it could cause a provider to bill "according to
              > that amount needed"
              > which was considered to be fraud. Likewise it's the
              > same reason the rep
              > cannot give out U&C amounts over the phone.
              >
              >
              >
              > It sounds like you are mostly dealing with indemnity plans?
              > As there is a
              > whole other world with PPO's HMO's etc.
              >
              >
              >
              >
              >
              > Linda Walker
              >
              > Practice Managers Resource & Networking Community
              > <http://www.billerswebsite.com>
              > http://www.billerswebsite.com
              > A division of K&L Media, LLC
              > <http://www.klmediallc.com>
              > http://www.klmediallc.com
              >
              > Website Design & Management for the Medical Services
              > Industry
              >
              >
              >
              >
              >
              >
              >
              >
              >
              > From: MedicalBillers@yahoogroups.com
              <mailto:MedicalBillers%40yahoogroups.com>
              > [mailto:MedicalBillers@yahoogroups.com
              <mailto:MedicalBillers%40yahoogroups.com> ]
              > On Behalf Of Carol Roush
              > Sent: Saturday, July 12, 2008 9:58 AM
              > To: MedicalBillers@yahoogroups.com
              <mailto:MedicalBillers%40yahoogroups.com>
              > Subject: [MedicalBillers] Help with calculating
              > coinsurance, pt portion and
              > percentages
              >
              >
              >
              > Hello Everyone :)
              >
              > Soooo, with my new job, I'm learning I'm the one
              > that inserts the DOS,
              > procedure code, amount billed (fee schedule), insurance
              > contracted rate,
              > patient portion and co-insurance amount in the Excel
              > spreadsheet. This is
              > how my supervisor/owner of the business does the billing.
              >
              > I'm slowly learning how to figure out what the co-ins
              > which is the
              > contracted rate x the percentage of what the pt pays.
              >
              > I also learned that 100% of the contracted rate is the pt
              > portion until the
              > deductible is met. When my supervisor went over all the
              > information she did
              > with me, it went over my head a bit. I had never learned
              > this in class.
              > Well, not these calculations.
              >
              > I still have to learn how to find out what was met and
              > figure out remaining
              > visits and such. Still not clear about it. I thought the
              > accountant/biller
              >
              > Everyone knows what I'm talking about? if you have any
              > other calculation
              > formulas to share with me to help me out at my job with
              > insurance....please
              > let me know! It's greatly appreciated!
              >
              > Thanks!,
              >
              > Carol
              >
              >
              >
              >
              >
              > [Non-text portions of this message have been removed]





              [Non-text portions of this message have been removed]
            • Joktan Edison
              Linda, Thanks for the wonderful explaination.   ... From: kishore kumar Subject: RE: [MedicalBillers] Help with calculating
              Message 6 of 9 , Jul 12, 2008
              • 0 Attachment
                Linda, Thanks for the wonderful explaination.
                 

                --- On Sat, 7/12/08, kishore kumar <kishorekk_k@...> wrote:

                From: kishore kumar <kishorekk_k@...>
                Subject: RE: [MedicalBillers] Help with calculating coinsurance, pt portion and percentages
                To: MedicalBillers@yahoogroups.com
                Date: Saturday, July 12, 2008, 8:11 AM






                Heyy... Linda,

                Marvelous Job Buddyy...!!! keep it up..!!

                Regards,
                Kishore KK,
                IRS specialist, Idaho.

                --- On Sat, 7/12/08, Lin <italiandoll1967@ yahoo.com> wrote:
                From: Lin <italiandoll1967@ yahoo.com>
                Subject: RE: [MedicalBillers] Help with calculating coinsurance, pt portion and percentages
                To: MedicalBillers@ yahoogroups. com
                Date: Saturday, July 12, 2008, 8:33 PM

                Hmm..

                << the co-ins which is the contracted rate x the percentage of what the pt

                pays.>>

                Coinsurance is simply A PORTION of the patient's cost sharing in the plan.

                For example if a plan pays 80% of U&C the patient's out of pocket is 20%

                plus any amount over U&C. If it's a plan the provider participates with, the

                patient then pays their copay and is not responsible for the difference

                between the allowed amount and billed amount.

                << I also learned that 100% of the contracted rate is the pt portion until

                the deductible is met.>>

                Yes, that's correct if the patient has a deductible to meet, they are

                responsible for full payment until their deductible is met. Depending on

                how the office does benefit verifications, this is something that can be

                found out by verifying benefits and documenting the phone call. A scenario

                might go like this: The office calls the carrier and inquires about

                benefits, the rep says the patient has a $200 deductible which HAS not been

                met as of that date. Depending on the practices office policy they can opt

                to bill the patient later for the amount going towards deductible or they

                can request the fee at the time of service. The rep can only tell you a

                deductible has or has not been met as of that date. With Medicare for

                example a deductible is often met within a visit or two the rep might even

                be able to tell you there are XX amount of claims in the system which HAVE

                NOT been processed which basically hints to you that by the time your claim

                is processed the deductible will have been met.

                When I worked as a claims examiner we were trained to never give out the

                dollar amount of the deductible yet to be reached, the reason was simply

                that it could cause a provider to bill "according to that amount needed"

                which was considered to be fraud. Likewise it's the same reason the rep

                cannot give out U&C amounts over the phone.

                It sounds like you are mostly dealing with indemnity plans? As there is a

                whole other world with PPO's HMO's etc.

                Linda Walker

                Practice Managers Resource & Networking Community

                <http://www.billersw ebsite.com> http://www.billersw ebsite.com

                A division of K&L Media, LLC

                <http://www.klmedial lc.com> http://www.klmedial lc.com

                Website Design & Management for the Medical Services Industry

                From: MedicalBillers@ yahoogroups. com [mailto:MedicalBill ers@ yahoogroups. com]

                On Behalf Of Carol Roush

                Sent: Saturday, July 12, 2008 9:58 AM

                To: MedicalBillers@ yahoogroups. com

                Subject: [MedicalBillers] Help with calculating coinsurance, pt portion and

                percentages

                Hello Everyone :)

                Soooo, with my new job, I'm learning I'm the one that inserts the DOS,

                procedure code, amount billed (fee schedule), insurance contracted rate,

                patient portion and co-insurance amount in the Excel spreadsheet. This is

                how my supervisor/owner of the business does the billing.

                I'm slowly learning how to figure out what the co-ins which is the

                contracted rate x the percentage of what the pt pays.

                I also learned that 100% of the contracted rate is the pt portion until the

                deductible is met. When my supervisor went over all the information she did

                with me, it went over my head a bit. I had never learned this in class.

                Well, not these calculations.

                I still have to learn how to find out what was met and figure out remaining

                visits and such. Still not clear about it. I thought the accountant/biller

                Everyone knows what I'm talking about? if you have any other calculation

                formulas to share with me to help me out at my job with insurance... .please

                let me know! It's greatly appreciated!

                Thanks!,

                Carol

                [Non-text portions of this message have been removed]











                [Non-text portions of this message have been removed]


















                [Non-text portions of this message have been removed]
              • Lin
                Your very welcome. Linda Walker Practice Managers Resource & Networking Community http://www.billerswebsite.com A division of
                Message 7 of 9 , Jul 12, 2008
                • 0 Attachment
                  Your very welcome.





                  Linda Walker

                  Practice Managers Resource & Networking Community
                  <http://www.billerswebsite.com> http://www.billerswebsite.com
                  A division of K&L Media, LLC
                  <http://www.klmediallc.com> http://www.klmediallc.com

                  Website Design & Management for the Medical Services Industry







                  From: MedicalBillers@yahoogroups.com [mailto:MedicalBillers@yahoogroups.com]
                  On Behalf Of Joktan Edison
                  Sent: Saturday, July 12, 2008 12:38 PM
                  To: MedicalBillers@yahoogroups.com
                  Subject: RE: [MedicalBillers] Help with calculating coinsurance, pt portion
                  and percentages



                  Linda, Thanks for the wonderful explaination.


                  --- On Sat, 7/12/08, kishore kumar <kishorekk_k@...
                  <mailto:kishorekk_k%40yahoo.com> > wrote:

                  From: kishore kumar <kishorekk_k@... <mailto:kishorekk_k%40yahoo.com>
                  >
                  Subject: RE: [MedicalBillers] Help with calculating coinsurance, pt portion
                  and percentages
                  To: MedicalBillers@yahoogroups.com <mailto:MedicalBillers%40yahoogroups.com>

                  Date: Saturday, July 12, 2008, 8:11 AM

                  Heyy... Linda,

                  Marvelous Job Buddyy...!!! keep it up..!!

                  Regards,
                  Kishore KK,
                  IRS specialist, Idaho.

                  --- On Sat, 7/12/08, Lin <italiandoll1967@ yahoo.com> wrote:
                  From: Lin <italiandoll1967@ yahoo.com>
                  Subject: RE: [MedicalBillers] Help with calculating coinsurance, pt portion
                  and percentages
                  To: MedicalBillers@ yahoogroups. com
                  Date: Saturday, July 12, 2008, 8:33 PM

                  Hmm..

                  << the co-ins which is the contracted rate x the percentage of what the pt

                  pays.>>

                  Coinsurance is simply A PORTION of the patient's cost sharing in the plan.

                  For example if a plan pays 80% of U&C the patient's out of pocket is 20%

                  plus any amount over U&C. If it's a plan the provider participates with, the

                  patient then pays their copay and is not responsible for the difference

                  between the allowed amount and billed amount.

                  << I also learned that 100% of the contracted rate is the pt portion until

                  the deductible is met.>>

                  Yes, that's correct if the patient has a deductible to meet, they are

                  responsible for full payment until their deductible is met. Depending on

                  how the office does benefit verifications, this is something that can be

                  found out by verifying benefits and documenting the phone call. A scenario

                  might go like this: The office calls the carrier and inquires about

                  benefits, the rep says the patient has a $200 deductible which HAS not been

                  met as of that date. Depending on the practices office policy they can opt

                  to bill the patient later for the amount going towards deductible or they

                  can request the fee at the time of service. The rep can only tell you a

                  deductible has or has not been met as of that date. With Medicare for

                  example a deductible is often met within a visit or two the rep might even

                  be able to tell you there are XX amount of claims in the system which HAVE

                  NOT been processed which basically hints to you that by the time your claim

                  is processed the deductible will have been met.

                  When I worked as a claims examiner we were trained to never give out the

                  dollar amount of the deductible yet to be reached, the reason was simply

                  that it could cause a provider to bill "according to that amount needed"

                  which was considered to be fraud. Likewise it's the same reason the rep

                  cannot give out U&C amounts over the phone.

                  It sounds like you are mostly dealing with indemnity plans? As there is a

                  whole other world with PPO's HMO's etc.

                  Linda Walker

                  Practice Managers Resource & Networking Community

                  <http://www.billersw ebsite.com> http://www.billersw ebsite.com

                  A division of K&L Media, LLC

                  <http://www.klmedial lc.com> http://www.klmedial lc.com

                  Website Design & Management for the Medical Services Industry

                  From: MedicalBillers@ yahoogroups. com [mailto:MedicalBill ers@ yahoogroups.
                  com]

                  On Behalf Of Carol Roush

                  Sent: Saturday, July 12, 2008 9:58 AM

                  To: MedicalBillers@ yahoogroups. com

                  Subject: [MedicalBillers] Help with calculating coinsurance, pt portion and

                  percentages

                  Hello Everyone :)

                  Soooo, with my new job, I'm learning I'm the one that inserts the DOS,

                  procedure code, amount billed (fee schedule), insurance contracted rate,

                  patient portion and co-insurance amount in the Excel spreadsheet. This is

                  how my supervisor/owner of the business does the billing.

                  I'm slowly learning how to figure out what the co-ins which is the

                  contracted rate x the percentage of what the pt pays.

                  I also learned that 100% of the contracted rate is the pt portion until the

                  deductible is met. When my supervisor went over all the information she did

                  with me, it went over my head a bit. I had never learned this in class.

                  Well, not these calculations.

                  I still have to learn how to find out what was met and figure out remaining

                  visits and such. Still not clear about it. I thought the accountant/biller

                  Everyone knows what I'm talking about? if you have any other calculation

                  formulas to share with me to help me out at my job with insurance... .please

                  let me know! It's greatly appreciated!

                  Thanks!,

                  Carol

                  [Non-text portions of this message have been removed]

                  [Non-text portions of this message have been removed]

                  [Non-text portions of this message have been removed]





                  [Non-text portions of this message have been removed]
                • Deb Tru
                  Linda, Do you have any ideas or resources that you can share concerning the differences in the insurance coverages? PPO, HMO, Indemnity: These are words
                  Message 8 of 9 , Jul 15, 2008
                  • 0 Attachment
                    Linda, Do you have any ideas or resources that you can share
                    concerning the differences in the insurance coverages? PPO, HMO,
                    Indemnity: These are words that I am not familiar with and would
                    like to access a website or book that would explain SIMPLY what they
                    are, the differences in them and how they work.

                    Thanks!

                    Deb







                    At 08:03 AM 7/12/2008, you wrote:

                    >Hmm..
                    >
                    ><< the co-ins which is the contracted rate x the percentage of what the pt
                    >pays.>>
                    >
                    >Coinsurance is simply A PORTION of the patient's cost sharing in the plan.
                    >For example if a plan pays 80% of U&C the patient's out of pocket is 20%
                    >plus any amount over U&C. If it's a plan the provider participates with, the
                    >patient then pays their copay and is not responsible for the difference
                    >between the allowed amount and billed amount.
                    >
                    ><< I also learned that 100% of the contracted rate is the pt portion until
                    >the deductible is met.>>
                    >
                    >Yes, that's correct if the patient has a deductible to meet, they are
                    >responsible for full payment until their deductible is met. Depending on
                    >how the office does benefit verifications, this is something that can be
                    >found out by verifying benefits and documenting the phone call. A scenario
                    >might go like this: The office calls the carrier and inquires about
                    >benefits, the rep says the patient has a $200 deductible which HAS not been
                    >met as of that date. Depending on the practices office policy they can opt
                    >to bill the patient later for the amount going towards deductible or they
                    >can request the fee at the time of service. The rep can only tell you a
                    >deductible has or has not been met as of that date. With Medicare for
                    >example a deductible is often met within a visit or two the rep might even
                    >be able to tell you there are XX amount of claims in the system which HAVE
                    >NOT been processed which basically hints to you that by the time your claim
                    >is processed the deductible will have been met.
                    >
                    >When I worked as a claims examiner we were trained to never give out the
                    >dollar amount of the deductible yet to be reached, the reason was simply
                    >that it could cause a provider to bill "according to that amount needed"
                    >which was considered to be fraud. Likewise it's the same reason the rep
                    >cannot give out U&C amounts over the phone.
                    >
                    >It sounds like you are mostly dealing with indemnity plans? As there is a
                    >whole other world with PPO's HMO's etc.
                    >
                    >Linda Walker
                    >
                    >Practice Managers Resource & Networking Community
                    ><<http://www.billerswebsite.com>http://www.billerswebsite.com>
                    >http://www.billerswebsite.com
                    >A division of K&L Media, LLC
                    ><<http://www.klmediallc.com>http://www.klmediallc.com>
                    >http://www.klmediallc.com
                    >
                    >Website Design & Management for the Medical Services Industry
                    >
                    >From:
                    ><mailto:MedicalBillers%40yahoogroups.com>MedicalBillers@yahoogroups.com
                    >[mailto:MedicalBillers@yahoogroups.com]
                    >On Behalf Of Carol Roush
                    >Sent: Saturday, July 12, 2008 9:58 AM
                    >To: <mailto:MedicalBillers%40yahoogroups.com>MedicalBillers@yahoogroups.com
                    >Subject: [MedicalBillers] Help with calculating coinsurance, pt portion and
                    >percentages
                    >
                    >Hello Everyone :)
                    >
                    >Soooo, with my new job, I'm learning I'm the one that inserts the DOS,
                    >procedure code, amount billed (fee schedule), insurance contracted rate,
                    >patient portion and co-insurance amount in the Excel spreadsheet. This is
                    >how my supervisor/owner of the business does the billing.
                    >
                    >I'm slowly learning how to figure out what the co-ins which is the
                    >contracted rate x the percentage of what the pt pays.
                    >
                    >I also learned that 100% of the contracted rate is the pt portion until the
                    >deductible is met. When my supervisor went over all the information she did
                    >with me, it went over my head a bit. I had never learned this in class.
                    >Well, not these calculations.
                    >
                    >I still have to learn how to find out what was met and figure out remaining
                    >visits and such. Still not clear about it. I thought the accountant/biller
                    >
                    >Everyone knows what I'm talking about? if you have any other calculation
                    >formulas to share with me to help me out at my job with insurance....please
                    >let me know! It's greatly appreciated!
                    >
                    >Thanks!,
                    >
                    >Carol
                    >
                    >[Non-text portions of this message have been removed]
                    >
                    >


                    [Non-text portions of this message have been removed]
                  • Lin
                    I recommend two books and they come out in updates every year or two: Insurance Handbook for the Medical Office and Understanding Medical Insurance.. both
                    Message 9 of 9 , Jul 15, 2008
                    • 0 Attachment
                      I recommend two books and they come out in updates every year or two:



                      Insurance Handbook for the Medical Office and Understanding Medical
                      Insurance.. both those books in the most recent editions will be invaluable
                      to you, I can just about promise that <g>





                      Linda Walker

                      Practice Managers Resource & Networking Community
                      <http://www.billerswebsite.com> http://www.billerswebsite.com
                      A division of K&L Media, LLC
                      <http://www.klmediallc.com> http://www.klmediallc.com

                      Website Design & Management for the Medical Services Industry









                      From: MedicalBillers@yahoogroups.com [mailto:MedicalBillers@yahoogroups.com]
                      On Behalf Of Deb Tru
                      Sent: Tuesday, July 15, 2008 9:46 PM
                      To: MedicalBillers@yahoogroups.com
                      Subject: RE: [MedicalBillers] Help with calculating coinsurance, pt portion
                      and percentages



                      Linda, Do you have any ideas or resources that you can share
                      concerning the differences in the insurance coverages? PPO, HMO,
                      Indemnity: These are words that I am not familiar with and would
                      like to access a website or book that would explain SIMPLY what they
                      are, the differences in them and how they work.

                      Thanks!

                      Deb

                      At 08:03 AM 7/12/2008, you wrote:

                      >Hmm..
                      >
                      ><< the co-ins which is the contracted rate x the percentage of what the pt
                      >pays.>>
                      >
                      >Coinsurance is simply A PORTION of the patient's cost sharing in the plan.
                      >For example if a plan pays 80% of U&C the patient's out of pocket is 20%
                      >plus any amount over U&C. If it's a plan the provider participates with,
                      the
                      >patient then pays their copay and is not responsible for the difference
                      >between the allowed amount and billed amount.
                      >
                      ><< I also learned that 100% of the contracted rate is the pt portion until
                      >the deductible is met.>>
                      >
                      >Yes, that's correct if the patient has a deductible to meet, they are
                      >responsible for full payment until their deductible is met. Depending on
                      >how the office does benefit verifications, this is something that can be
                      >found out by verifying benefits and documenting the phone call. A scenario
                      >might go like this: The office calls the carrier and inquires about
                      >benefits, the rep says the patient has a $200 deductible which HAS not been
                      >met as of that date. Depending on the practices office policy they can opt
                      >to bill the patient later for the amount going towards deductible or they
                      >can request the fee at the time of service. The rep can only tell you a
                      >deductible has or has not been met as of that date. With Medicare for
                      >example a deductible is often met within a visit or two the rep might even
                      >be able to tell you there are XX amount of claims in the system which HAVE
                      >NOT been processed which basically hints to you that by the time your claim
                      >is processed the deductible will have been met.
                      >
                      >When I worked as a claims examiner we were trained to never give out the
                      >dollar amount of the deductible yet to be reached, the reason was simply
                      >that it could cause a provider to bill "according to that amount needed"
                      >which was considered to be fraud. Likewise it's the same reason the rep
                      >cannot give out U&C amounts over the phone.
                      >
                      >It sounds like you are mostly dealing with indemnity plans? As there is a
                      >whole other world with PPO's HMO's etc.
                      >
                      >Linda Walker
                      >
                      >Practice Managers Resource & Networking Community
                      ><<http://www.billerswebsite.com>http://www.billerswebsite.com>
                      >http://www.billerswebsite.com
                      >A division of K&L Media, LLC
                      ><<http://www.klmediallc.com>http://www.klmediallc.com>
                      >http://www.klmediallc.com
                      >
                      >Website Design & Management for the Medical Services Industry
                      >
                      >From:
                      ><mailto:MedicalBillers%40yahoogroups.com>MedicalBillers@yahoogroups.com
                      <mailto:MedicalBillers%40yahoogroups.com>
                      >[mailto:MedicalBillers@yahoogroups.com
                      <mailto:MedicalBillers%40yahoogroups.com> ]
                      >On Behalf Of Carol Roush
                      >Sent: Saturday, July 12, 2008 9:58 AM
                      >To: <mailto:MedicalBillers%40yahoogroups.com>MedicalBillers@yahoogroups.com
                      <mailto:MedicalBillers%40yahoogroups.com>
                      >Subject: [MedicalBillers] Help with calculating coinsurance, pt portion and
                      >percentages
                      >
                      >Hello Everyone :)
                      >
                      >Soooo, with my new job, I'm learning I'm the one that inserts the DOS,
                      >procedure code, amount billed (fee schedule), insurance contracted rate,
                      >patient portion and co-insurance amount in the Excel spreadsheet. This is
                      >how my supervisor/owner of the business does the billing.
                      >
                      >I'm slowly learning how to figure out what the co-ins which is the
                      >contracted rate x the percentage of what the pt pays.
                      >
                      >I also learned that 100% of the contracted rate is the pt portion until the
                      >deductible is met. When my supervisor went over all the information she did
                      >with me, it went over my head a bit. I had never learned this in class.
                      >Well, not these calculations.
                      >
                      >I still have to learn how to find out what was met and figure out remaining
                      >visits and such. Still not clear about it. I thought the accountant/biller
                      >
                      >Everyone knows what I'm talking about? if you have any other calculation
                      >formulas to share with me to help me out at my job with insurance....please
                      >let me know! It's greatly appreciated!
                      >
                      >Thanks!,
                      >
                      >Carol
                      >
                      >[Non-text portions of this message have been removed]
                      >
                      >

                      [Non-text portions of this message have been removed]





                      [Non-text portions of this message have been removed]
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