The Insurance Plan Fee Schedule (IPFS) screen allows users to create fee schedules that automatically fill the Insurance, Plan Benefit and Insurance Plan Discount information for a Spectacle Lenses, Lens Treatments, Services, Frames, Contact Lenses and Other items when associated Insurance Plans are specified in an Order.

IPFS pricing is applied to Orders if certain conditions are met:

§ The patient has a Provider assigned on the Profile tab of the Patient screen.

§ The Insurance Plan is selected on the Patient tab of the Order screen. 

§ You do not override the IPFS pricing with other copays or benefits.

 

When these conditions are met the IPFS pricing is automatic in the Order and the prices of Eligible items are changed to match the IPFS.

Users can also set up a Frame price calculation formula based on the Whole, Retail or Material cost of the frames. If no frame information is setup, the frame price will appear as its retail. When a frame is entered in an insurance order pertaining to the plan, the patient cost will be calculated from the rules setup in this section.

For Non-Insurance Supplied items, the Patient Pays is usually calculated as follows:

Patient Pays = Charge – Addl Copay – Ins Pays – Ins Gap – Discount

The Ins Gap is either considered part of the discount or can be specified as a Write-Off.

The sum of the Addl Copay and Ins Pays cannot exceed the Ins Allowance

The Discount field is calculated from the Discount and Type fields, which are editable.

For Insurance Supplied items, the amount the patient pays depends on whether it can be specified in the IPFS screen.

Any additional discounts and multipliers can be entered in this section as well.

Allowance Amount: The Allowance Amount is the maximum allowance amount your optical shop will cover.

Insurance Pays: The Insurance Pays is the maximum amount that the insurance company will cover.

NOTE: The Insurance Pays field automatically rests to zero when the insurance is removed from an order. This also removes the dispensing fees and copayments.

Patient Pays: The Patient Pays is the amount the patient is responsible for paying for frames. The Patient Pays is calculated by subtracting the Charge, Addl Copay, Ins Pays, Ins Gap and Discount from the Charge (plus Tax if applicable).

Dispensing Fee: The Dispensing Fee is the amount the insurance company is contracted to compensate the optical shop.

Overage Multiplier: If the calculation is based on wholesale price, the Overage Multiplier multiplies the overage cost to calculate the patient responsibility.

Overage Discount: If the calculation is based on retail price, then the Overage Discount is the percentage discount subtracted from the remaining cost after the Insurance Pays is subtracted from the Retail price.

CL Allowance: The CL Allowance is the maximum allowance amount your shop will cover for contact lenses.

Eligible: The Eligible checkbox specifies whether the insurance plan pays for or discounts the procedure entirely or partially.

Lenses can be formed as bundles of V-Codes with a single identifying Lens UPC. For lens bundles, the Code to be billed to the insurance is derived from procedures.  In the Procedure Code setup screen, each V-code for the lens bundle Lens UPC must be created.  During Inventory setup each lens bundle Lens UPC must be linked to the procedure codes contained in the lens bundle.  The lens will appear once for each Procedure code that is linked to it in inventory. For more information, refer to the Spectacle Lens section.

 

All Procedure codes and lens bundle lenses convey to each IPFS Table where pricing for each item is determined by the Insurance Plan.

 

To modify insurance fee schedules:

Select File > Setup > Insurance Fee Schedule from the menu bar to open the IPFS screen.

Click to highlight the plan for which you want to setup a schedule.

To setup a frame allowance, click to highlight the Type drop-down list in the Frame section and choose whether the allowance will be based on Whole, Retail or Material price. Fill in the Allowance Amount, Insurance Pays, Patient Pays, Dispensing Fee, Overage Discount and CL Allowance fields.  If you are creating the schedule for insurance supplied frames, check the Insurance Supplied Frames field. To set frames overage to procedure code V2025, check the Overage to V2025 checkbox.

In the Copay/Other section, fill in the Copay Exam, Copay Frame and Copay Material fields. If you are creating a fee schedule for non-service insurance supplied items, check the Insurance Supplied Lens/Other checkbox.

NOTE: Insurance Supplied items specify items that are sent completed from the lab and do not deplete inventory. Items that are not specified as insurance supplied are provided by the store and do deplete inventory.

Services cannot be specified as Insurance Supplied.

Benefits and copayments set up in the Insurance tab of the Patient module take precedence over benefits and copayments assigned in the IPFS setup screen.  

Check the Combine lens codes to V2781 checkbox to combine lens codes between the range of V21xx, V22xx and/or V23xx to the V2781 Procedure code (V-code) when the associated insurance plan is selected on a Spectacle Lens order.

NOTE: A validation has been added that prevents the Combine lens codes to V2781 checkbox to be saved in a checked state if the Insurance Supplied Lens/Others checkbox is checked.

To set up fee schedule information for individual spectacle lens items and/or procedure codes, click the Spectacle Lens, Other, Services, Lens Treatments, Frames or Contact lens radio button in the Filter section to filter your V-codes by the item type or service where you want to apply the fee schedule.

NOTE: If the insurance plan is linked to an IPFS, those insurance fees automatically transfer to the Invoice tab of the Order module. If you modify or add values on the Order tab of the Patient module or the Patient tab of the Order module, they will also transfer into the Invoice tab. The IPFS copay transfers to its own column on the Invoice. For more information, refer to the Patients Use and Detailed Orders Use sections.

You can also filter your V-codes by more specific criteria by clicking Filter… to open the Filter condition screen and filling in one or more fields. When you’re finished, click OK to save. If you do not want to save, click Cancel to return to the IPFS screen. To remove a filter, click Clear filter to clear all fields.

NOTE: It is recommended you use the Filter screen if you are writing free schedules for multiple Spectacle Lenses tied to the same procedure codes.

If you are creating a fee schedule for Eyefinity, click VSP Dispensing Fees… to open the VSP Dispensing Fees screen and fill in the fields. When you’re finished, click Close to save .

Click to highlight the lens/V-code you want to setup a fee schedule for in the list at the lower left portion of the screen and scroll the to the right to fill in the fields in the Copay, Contracted Fee, Insurance Pay and Discount columns, or click Details... to open the Fee Details screen. Make sure the Eligible checkbox is checked. If you are applying a discount, click to highlight the Discount Type drop-down list, and select whether you want the discount to be a Amount, Percent or Retail (%).

NOTE: The Eligible checkbox must be checked for the Insurance Pays values to carry over to the Charges tab of the insurance claim.

If you select Amount as the Discount Type, the figure entered in the Discount field is the amount taken from the cost of the selected inventory item type. If you select Percent, the figure entered is the percentage taken from the cost of the item. If you select Retail (%), the figure entered is the percentage taken from the retail cost of the item.

Users can specify Modifiers and Alternate CPT codes from the appropriate columns for insurance companies that use codes different from standard procedure codes (i.e., EyeMed, Spectra).

NOTE: If the Modifier and Alternate CPT columns are not filled, the default values will carry over from the Procedure Codes setup screen.

The Modifier drop-down list will populate all existing modifiers. You can modify your modifier selection by selecting File > Setup > Modifier from the menu bar to open the Modifier setup screen. For more information, refer to the Code Modifiers Setup section.

The Alternate CPT drop-down list will populate all existing procedure codes depending on the service and/or item type selected. You can modify your procedure code selection by selecting File > Setup > Procedure Codes from the menu bar to open the Procedure Codes setup screen. For more information, refer to the Insurance Procedure Codes Setup section.

If you would like to enter the same fee schedule information for more than one V-code, hold the  Shift key on your keyboard, click to highlight multiple codes and click Details to open the Fee Details screen. When you’re finished, click OK to save. If you do not want to save, click Cancel to return to the Insurance Plan Fee Schedule screen.

To rearrange the order your V-codes are sorted in, click Sort... to open the  Sort screen. Click and drag the values you want to use to sort from the Columns Available for Sorting list into the Sort Columns list. If you want to remove a sorting column, click and drag the value from the Sort Columns box into the Columns Available for Sorting list. If you want the value to display in ascending order, check the Ascending checkbox. When you’re finished, click OK to save. If you do not want to save, click Cancel to return to the IPFS screen.

To copy existing fee schedule from one plan to another plan, click to highlight the insurance plan to where you want the fee schedule copied and click Copy From… to open the Copy Fee Schedule screen. Click to highlight the insurance plan from where you want to copy the fee schedule and click OK. If you do not want to copy a fee schedule, click Cancel to return to the IPFS screen.

Click the Save and Close icons on the toolbar after you’re done making changes to this screen. You may be prompted to restart the application before the changes take effect.

Examples:

Frames schedule based on Wholesale: If the frame calculation is based on wholesale, you can define an overage multiplier that multiplies the overage cost to calculate the patient responsibility.

Non-Insurance Supplied

The discount for a non-insurance supplied wholesale frame order is the retail cost subtracted by the difference between the group cost of the frame and the allowance amount multiplied by the overage multiplier. For example, if the Allowance Amount is $55 and the Overage Multiplier is 2, you will have:

Allowance Amount = $55, Overage Multiplier = 2

When you apply this formula to a frame with a Retail Cost of $200 and a Group Cost of $100, the discount will be:

$200 – 2($100 – 55) = $200 – 2($45) = $200 – 90 = $110.

The price the patient pays is calculated by subtracting the Charge, Addl Copay, Ins Pays, Ins Gap and Discount from the Charge (plus Tax if applicable). For example, if the Addl Copay is $0, Ins Pays is $55, Ins Gap is $0 and Discount is $110, you will have:

Ins Pays = $55, Discount = $110

When you apply this formula to a frame with a Charge of $200, the patient will pay:

$200 - $55 - $110 = $35.

If the Allowance Amount is more than the Group Cost, the group cost alone is used to calculate the discount. For example, if the Allowance amount is $55, the Insurance Pays is $55, and the Overage Multiplier is 2, you will have:

Allowance amount = $110, Overage Multipler = 2

When you apply this formula to a frame with a Retail Cost of $200 and a Group Cost of $50, the discount will be:

$200 – 2($50) = $200 – $100 = $100.

NOTE: If the Allowance Amount is higher than the Group Cost, the patient pays nothing.

If a Dispensing Fee is specified, it will be added as charge in the order payable by the insurance for the amount of the dispensing fees.

Insurance Supplied

The price the insurance pays for an insurance supplied wholesale frame order is the difference between the group cost and allowance amount multiplied by negative one. For example, if the Allowance Amount is $55, when you apply this formula to a frame with Group Cost of $100, the insurance will pay:

-1($100 - $55) = -1($45) = $-45.

NOTE: If the difference between the group cost and allowance amount is less than zero BEFORE they are multiplied by negative one, the patient pays nothing.

The price the patient pays for an  insurance supplied wholesale frame order is the difference between the group cost of the frame and the allowance amount multiplied by the overage multiplier (plus Tax, if applicable). For example, if the Allowance Amount is $55 and the Overage Multiplier is 2, you will have:

Allowance Amount = $55, Overage Multiplier = 2

When you apply this formula to a frame with a Group Cost of $100, patient will pay:

2($100 - $55) = 2($45) = $90.

The discount is calculated by specifying the difference between the retail cost of the frame , the amount the insurance pays and the amount the patient pays. For example, if the Ins Pays is $-45 and the Patient Pays is $90, you will have:

Ins Pays = $-45, Patient Pays = $90

When you apply this formula to a frame with a Retail Cost of $200, the discount will be:

$200 – (-45) – 90 = $200 + 45 – 90 = $245 – 90 = $155.

Frame schedule based on Retail: If the frame calculation is based on retail, you can define an overage discount on the remaining price after the allowance amount is subtracted from the retail cost of the frame.

Non-Insurance Supplied

The discount is calculated by subtracting the Charge, Addl Copay, Ins Pays and Ins Gap and multiplying this number by the overage multiplier. For example, if the Addl Copay is $0, Ins Pays is $55, Ins Gap is $0 and the overage multiplier is 20%, you will have:

Ins Pays = $55, Overage Discount = 20%

When you apply this formula to a frame with a Retail Cost of $200, the discount will be:

20%(200 - 55) = 20%(145) = $29.

The price the patient pays is calculated by subtracting the Charge, Addl Copay, Ins Pays, Ins Gap and Discount from the Charge (plus Tax if applicable). For example, if the Addl Copay is $0, Ins Pays is $55, Ins Gap is $0 and Discount is $29, you will have:

Ins Pays = $55, Discount = $29

When you apply this formula to a frame with a Retail Cost of $200, the patient will pay:

$200 - $55 - $29 = $116.

NOTE: If the Allowance amount is higher than the Retail Cost, the patient pays nothing.

Insurance Supplied

The discount is calculated by specifying the difference between the Charge, Patient Pays and Ins Pays. For example, if the Patient Pays is $55 and the Ins Pays is $55, you will have:

Patient Pays = $55, Ins Pays = $55

When you apply this formula to a frame with a Retail Cost of $200, the discount will be:

$200 – 55 – 55 = $145 - $55 = $90.

Frame schedule based on Material: If the frame calculation is based on the material allowance, the allowance amount is subtracted directly from the charge.

Non-Insurance Supplied

The allowance amount is added in a new line as a Material Allowance in the Invoice tab. For example, if the Allowance amount is $55, the Material Allowance will be $55.

The price the patient pays is normally calculated by subtracting the Charge, Addl Copay, Ins Pays, Ins Gap and Discount from the Charge (plus Tax if applicable). However, if there is a Material Allowance, this amount is also subtracted from the amount the patient pays.  For example, if the Addl Copay is $0, Ins Pays is $0, Ins Gap is $0 Discount is 20% and Material Allowance is $55, you will have:

Discount = 20%, Material Allowance = $55

When you apply this formula to a frame with a Retail Cost of $200, the patient will pay:

$200 – 20%($200) - $55 = $200 - $40 - $55 = $160 - $55 = $105.

NOTE: If the Allowance Amount is higher than the Retail Cost, the patient pays nothing.

Insurance Supplied

The discount is specified by subtracting the Charge, Patient Pays and Ins Pays. If the Patient Pays $65 and the Ins Pays $0, when you apply this formula to a frame with a Retail Cost of $200 the patient will pay:

$200 - $65 = $135.

The price the patient pays is specified in the free schedule. However, if there is a Material Allowance, this amount is also subtracted from the amount the patient pays. For example, if Patient Pays is $65 and Material Allowance is $55, when you apply this formula the patient will pay:

$65 - $55 = $10.

To setup VSP fee schedules:

Select the appropriate VSP insurance from the data window.

NOTE: DO NOT set up a rule for the Frame. This will be automatically calculated in the order from the information provided and VSP frame calculation formula.

Click the Spectacle Lens radio button in the Filter section to filter your VSP lens selection. Click to highlight the appropriate lens to enter the insurance and patient payment information.

NOTE: Before setting up the fee schedule you must add the VSP V-codes to the appropriate lenses by selecting File > Inventory > Spectacle Lens. For more information, refer to the Spectacle Lens section. 

Click the Services radio button in the Filter section to filter your VSP services selection. For Contact Lens orders you need to set up two services: Comprehensive Exam – Contact Lens and CL Refitting. You also need to specify the Insurance Pays as a 15% discount under the fee schedule. For example, if Comprehensive Exam – Contact Lens has a retail price of $59, the Insurance Pays $50.15. For more information, refer to the Services section.

For regular Exams you need to set up a separate Comprehensive Exam and specify insurance pays as how much VSP will pay you for it. For example, if the Comprehensive Exam has a Retail price of $110, the Insurance Pays $50.

Dispensing fees for VSP can be set up by clicking VSP Dispensing Fees in the IPFS screen.