This screen lets you add Fee Schedules to Insurance Plans. This feature automatically fills the insurance, patient and discount amount when the plan is specified in the order. When this is billed to the insurance, the amount billed is taken from inventory setup. The fee schedule can be defined for Spectacle Lenses, Lens Treatments and Services. You can also setup a Frame price calculation formula based on frame cost or retail price. For Spectacle Lenses, Lens Treatments and Services to appear they must be linked to a Procedure code (V-code) in inventory setup.
The frame allowance, retail or wholesale, can be setup along with insurance reimbursement. Any additional discounts and multipliers can be entered in this section as well. 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. If no frame information is setup the frame price will appear as its retail. You can setup the Frame calculation formula based on the cost or retail price of the frame. Allowance amount is the maximum allowance amount the insurance company will cover. Insurance pays is the amount that the insurance company will reimburse you. Patient pays is the amount the patient is responsible for. If the frame calculation is based on retail price, you can also define an overage percentage discount that is the percentage discount on the remaining amount above the allowance amount. Patient is responsible for the overage amounts above the allowance amount.
In order for lenses to appear in the list, V-codes for the lenses must be setup refer to Lens Inventory. The lens will appear once for each V-code that is linked to it in inventory. If a lens is linked to three procedure codes it will appear three times, once for each procedure code allowing you to setup the insurance and patient responsibility for each procedure. When the lens is entered in an insurance order pertaining to the plan the patient and insurance cost will be automatically calculated. Examples will be provided following the Insurance Fee Schedule Setup to illustrate how the different features of setting up an Insurance Fee Schedule work.
NOTE: Insurance Plans cannot be used in Quick Order
• To setup an Insurance Fee Schedule:
1. Follow the menu sequence … File | Setup | Insurance Fee Schedule or click on the Fee Schedule Button under Insurance Plan setup.
2. In the Insurance Plan Fee Schedule Screen highlight the plan for which you wish to setup the fee schedule.
3. To setup a Frame Allowance, in the Frame Section choose whether the allowance will be based on wholesale or retail price.
4. Enter the rest of the corresponding information in the Frame Section, for more information on what these fields actually represent see the examples following this setup.
5. If the procedure is covered by insurance and the insurance pays for the covered option enter the service fee in the Covered Option Service Fee Field; located on the lower portion of the screen to the right of the Patient Pays Column.
6. Locate the lens/V-code you wish to setup and highlight the record, then enter the Insurance Pays and Patient Pays Fields.
7. If you would like to enter the same Insurance Pays and Patient Pays values for numerous V-codes highlight those codes then click the Details Button, enter the values.
8. To sort your V-codes click the Sort Button then in the Sort Screen click and drag the values you wish to sort by from the Columns Available for Sorting Box to the Sort Columns Box.
9. To filter your V-codes using a specific criteria click the Filter Button then specify the criteria you wish to filter by.
10. The Copy From Button lets you copy the fee schedule from one plan to another. It will copy patient pays, insurance pays and covered option service fee to the fee schedule of the insurance plan in focus from the selected fee schedule.
11. If you would like to add another Fee Schedule go to step 2, otherwise click Save then Close from the menu toolbar.
Examples:
Frame schedule based on Retail price:
• Retail is equal or more than the Allowance amount:
Allowance amount = $100, Insurance pays = $55, Patient pays = $0, Overage Discount = 20%, Copay = $0
If the patient selects a Frame of Retail = $200, this would be calculated as Retail = read from inventory =
$200.
Insurance = insurance pays – co pay, or retail whichever is lower= $55
Discount = difference between allowance, insurance and patient plus overage discount(where overage is Frame Retail – Allowance) = ($100 - $55 - $0) + (20% of [ $200 - $100]) = $45 + $20 = $65.
Patient pays = patient pays + (overage amount * (100 – overage percentage discount)) + co pay = $0 +
$100 * (100% - 20%) = $100 * 80% = $80
• Retail is less than the allowance amount:
Allowance amount = $100, Insurance pays = $55, Patient pays = $0, Overage Discount = 20%, Copay = $0
If the patient selects a Frame of Retail = $50, this would be calculated as Retail = read from inventory =
$50.
Insurance = insurance pays – co pay, or retail whichever is lower= $50
Discount = difference between allowance, insurance and patient plus overage discount(where overage is
Frame Retail – Allowance) = ($100 – $50 - $0) + (20% of [$50 – $100]) = $50 + (-$10) = $50 + $0 = $50
NOTE: If the overage discount is negative it is set to zero.
Patient pays = patient pays + (overage amount x (100 – overage percentage discount)) + co pay = $0 +
$0 * (100% - 20%) = $0 * 80% = $0
Frame schedule based on Group cost:
If the frame calculation is based on group cost, you can also define an overage multiplier that multiplies the overage cost with the multiplier to calculate the patient responsibility.
• Group Cost is equal or more than the Allowance amount:
Allowance amount = $55, Insurance pays = $55, Patient pays = $0, Overage Multiplier = 2, Co pay = $0
If the patient selects a Frame of Cost = $100, this would be calculated as Retail = read from inventory =
$200 (assuming markup of 2 times).
Insurance = insurance pays – co pay, or group cost whichever is lower = $55
Patient pays = patient pays + overage x overage multiplier + co pay = $0 + ($100 - $55) x 2 = $90
• Group Cost is less than the Allowance amount:
Allowance amount = $55, Insurance pays = $55, Patient pays = $0, Overage Multiplier = 2, Co pay = $0
If the patient selects a Frame of Cost = $10, this would be calculated as Retail = read from inventory =
$100 (assuming markup of 10 times)
Insurance = insurance pays – co pay, or group cost whichever is lower = $10
Patient pays = patient pays + overage x overage multiplier + co pay = $0 + ($100 - $55) x 2 = $0
If you specify dispensing fees for the frame, it will be added as charge in the order payable by the insurance for the amount of the dispensing fees.
• To setup VSP Fee Schedule
NOTE: The fee schedule for VSP is setup differently than other insurance plans:
12. Frame: DO NOT setup a Rule for the Frame. This will be automatically calculated in the order from the information provided and VSP frame calculation formula.
13. Lenses: There is a special list of VSP lenses that will appear under this section. Before setting up the fee schedule you must add the V-codes to the lenses see topic on Lens Inventory. Once a record is highlighted you can enter the insurance and patient payment.
14. For Contact Lens Orders you need to setup two services "Comprehensive Exam – Contact Lens" and "CL Refitting" and specify insurance pays as 15% discount under the fee schedule. For example, Comprehensive Exam – Contact Lens Retail $59 Insurance Pays $50.15
15. For regular Exams you need to setup a separate "Comprehensive Exam" and specify insurance pays as how much VSP will pay you for it. For example, Comprehensive Exam Retail $110 Insurance Pays $50 (For information on setting up exams see the topic on Services)
16. Dispensing fees for VSP can be setup by clicking the VSP Dispensing Fees Button in the Insurance Plan Fee Schedule Screen.
See Also: