Question regarding patient insurance and billing

Dear All,

I’ve been trying out the insurance details in patient demographics and how to bill the insurance. But I believe how insurance works is different in my country than US.

In my country the patient with insurance is only billed a percentage of the amount of the service. For example, a patient has an insurance card that says “Contribution: 10% up to $100”. This means that the patient is required to pay only 10% of the service fees up to 100$, meaning the maximum amount that he can pay is $100, after that everything will be paid by the insurance company. Another example if the same patient is required to pay a service fee of $20 then the patient will only pay $2 and the rest $8 will be paid by the insurance company. I think in US this is called co-insurance. We don’t have such thing as co-pay.

So my question is, does OpenEMR supports such thing?

Would this max fee be based on a period of time or per visit? Does your insurance companies not take into account max payments based on client/coding?
For copay, sounds to me that for accounting purposes, your requirement is basically the same however, you could use a prepayment and reconcile in posting.

Max payment is based on visit, I believe.

Would you please tell me what do you mean by this?

For copay, isn’t copay means that the patient has to pay a fixed amount at each visit? If it’s true then it’s different than the above scenario, because the fee that would be paid by the patient is different depending on the service fee.

I can only tell what I’ve learned in my forays into billing and small clinic. Generally Providers have agreements with commercial Insurance which the copay can be fixed to a certain amount depending on policy patient carries. This is also true with say, U.S medicare Advantage private coinsurance. While copay in OpenEMR does not have to be a given amount at any visit, it can be set to a default copay depending on their policy/payer. At checkout/payment you may enter the amount collected for a copay and use payment option copay. This will setup as a payment for posting. The percentages will need to be up to the person taking payment. I don’t know that OpenEMR allows for maximum’s here but jeez, I’ve been fooled before:)

For billing insurance, depending on insurance company, there will generally be a set amount payer will pay against various billed procedures regardless of the amount you bill the payer, so in that regard, a max amount.

Maybe this helps some.

you could add a coinsurance choice under administration->lists->adjustment reasons but it would take code level modification to support the percentage adjustment like copay supports for a fixed amount

@sjpadgett Very helpful! Thank you.

@stephenwaite But using this I’ll be required to go to each invoice and adjust it manually, right?
I was thinking of entering the co-insurance in patient’s demographics, just like the co-pay.

Problem with setting an amount in Demographics is that amount will become an account receivable line item for each visit/encounter. I’m thinking that by leaving unset then the copay will carry forward as an adjustable amount set at payment time but still have the copay benefit during claim reconciliation.

good pts

since we’re talking about an adjustment which you can’t apply in fees->payment @A.Mangour are you familiar with eob posting screen (can get to it through past encounters->billing view or fees->posting->search)

oh, saw you are using charges panel from another post? Charges Panel and Prescription