8
Capitation
Payors can be configured as capitated. Patients that have capitated payor will have capitated charges that are zero priced. At end of month, a capitation charge is generated on the patient account to be billed to the payor along with any non-capitated charges.
Payor Set-up as Capitated
To set-up a Payor as capitated:
1 Enter a capitation charge code on the Payor Plan screen.
Patient Capitation Processing
To run capitation:
1 SYSTABLE.CAPDAY must be populated with day of the month on which capitation process should be executed. Leave SYSTABLE.CAPDAY blank to skip processing capitation.
2 Patients must be set-up with capitated payor. Charges that are capitated for the payor should price with a rate of zero. Non-capitated charges should receive a payor specific rate.
3 On the day indicated in SYSTABLE.CAPDAY, the process will execute in dayend and search for any patients with a capitated payor. If the patient has charges in the prior month (or current month if processing on last day of month) and does not already have a capitation charge, then a capitation charge will be generated to bill to the payor.
Generic Payor/Client Set-up
Generic payor/clients can be set-up then assigned to patients. At time of billing, a specific payor will then be selected based on the Clinic or Lab of the charges being billed. Generic payors would typically be used in one of the two following cases:
1 Medicare generic payor which must be billed based on the location of the lab where tests/services are provided.
2 Client generic payor picking which client to bill based on client associated with charges being billed.
Set-up Generic Payor
To set-up a generic payor:
1 Set-up payor plan with plan code = 999999 and pick Plan indicator to identify if detailed payor should be picked based on L=Lab or C=Clinic.
the plan code matching the clinic or lab code (depending on whether plan indicator is L=Lab or C=Clinic).
Processing Generic Payors
To use generic payors:
1 Assign generic payor to patient account.
2 Charges added with Clinic and COB of payor.
Transaction Roll-ups
Charges on Patient Accounts can be rolled up prior to billing to produce a single charge for billing.
Set-up Roll-up
Roll-up rules are configured in the Transaction Roll-up maintenance table.
To configure a roll-up rule:
1 Open Transaction > Roll-up Codes maintenance screen.
2 Enter a roll-up header record.
Company is the company identifies the Company the rule will be used by.
Rule ID is a unique name used to Identify the Roll-up Rule.
Tran Code indicates the new charge that will be generated by the Roll-up.
Roll-up Rule defines when the rollup should occur:
o 1 = Old Code Amount > New Code Amount roll-up will occur if the sum of the rates of the rolled up codes is greater than the rate of the new code to be created.
o 2 = All Codes Exist roll-up will occur if all non-optional charges to be rolled-up are found.
o 3 = All COB roll-up will occur if all non-optional charges to be rolled-up are found and are billable to the same COB (Cordination of Benefits).
Backout Code defines how the rolled-up codes should be backed out when the roll-up occurs.
o 1 = Reverse Old Codes will reverse out (Journal Out/J-out) the rolled-up transactions. This method is not recommend as it prevents ability to perform a subsequent Payor Change and backing out the roll-up.
o 2 = Back Out Dollar Amount will create reversing transactions flagging the old and
and then generate new transactions for the rolled-up charges which have the dollar amount of the New Transaction Code spread across them based on each charges dollar percent of total rolled-up charges. The New Transaction will have a zero dollar rate assigned.
o 4 = Prorate by Quantity will create reversing transactions flagged with ‘U’ status and then generate new transactions for the rolled-up charges with which have the dollar amount of the New Transaction Code spread across them based on each charges quantity percent of the total rolled-up charges. The New Transaction will have a zero dollar rate assigned.
3 Enter Details of charges to be rolled up for the rule.
Each line of detail represents charges that should be included with the roll-up. Charges will be indentified for the roll-up by matching the detail rule.
o Price List can be used to select charges which are all of the same price list. Price list will typically be used with Tran Code = 99999999 (all transactions of a particular price list) and with the Quantity field to indicate that a certain quantity of the rolled-up charges must exist on the account to match the roll-rolled-up requirement rule. Price List will also be used with the Optional flag to indicate that all charges belonging to a certain price list are optional, but should be rolled-up when then roll-up occurs.
o Quantity can be used to indicte if a minimum quantity of this charge or set of charges must exist for the roll-up rule to apply.
o Tran Code can be used to indentify a single charge to be required or included with the roll-up or the Tran Code can be set to ‘99999999’ to indicate that all charges in particular Price List are included.
o Patient Type can be used to indicate if the detail rule line only applies to a single Patient Type or ‘99’ for All Patient Types.
o Financial Class can be used to indicate if the detail rule line applies to only one Financial Class or ‘99’ for All Financial Classes.
dates within a specific period of time.
o Optional is used to indicate if the rule is required (unchecked) meaning the rule must be met for the roll-up to occur or optional (checked) meaning the indicated charges will be rolled up, but do not need to exist for the roll-up rule to apply.
4 Enter Roll-up Rule Priorities.
Multiple roll-up rules can apply depending on the details in the roll-up. The Priorities define what order the roll-ups should take. These priorities are identified by Financial Class and/or Payor + Plan.
o Financial Class can be used to indicate which Financial Class this priority belongs to.
o Payor + Plan can be used to indicate priority for a specific Payor and/or Plan.
o Priority defines the priority of this rule for the indicated Financial Class and Payor + Plan rule. Priority of 0 indicates the rule should be ignored. Priority of 1 is highest priority, 2 is second highest, etc.
for all detail charges which should be considered for the roll-up.
o Roll-up A, B, D and F are client specific Bundling Roll-ups. These roll-up types should not be used unless indicated by Implementation Specialist.
o Roll-up Y indicates the charge should roll-up.
o Roll-up X indicates the charge should explode into other charges.
o Blank indicates the charge should not roll-up.
appears before the In/Out field, on the Patient Transaction Entry, Detail screen, and on the Claims and Client Transaction screens.
Processing Roll-up
Charges will be added to a Patient Account and if flagged in the Transaction Rate rules will have Roll-up flag set to Y to indicate it should be included with roll-ups.
In the End of Day Process, prior to billing, roll-up will be checked to determine which if any roll-ups should apply. Accounts with new unbilled charges entered since the last End of Day Process which haven’t already been rolled-up will be checked.
The roll-up process will look for charges which are flagged for roll-up, but have not been rolled up or billed yet. Using the priorities identified, each roll-up rule will be checked to see if it applies based on the rule type and the details identified. If the rule applies, the transactions identified as the roll-up detail will be backed out in the method indicated and if necessary, re-applied with new dollar
amounts. All of the backed out transactions will be flagged with either a ‘J’ status for reversal or a ‘U’
status to indicate they have been rolled up. The new transaction will be generated.
Roll-up Flagged Transactions before Roll-Up Process:
After roll-up, flagged charges reversed with a ‘U’ status. New charge created is highlighted: