Reimbursements and Discounts in Cost Estimation

Help Guide for NextGen® Enterprise PM 8

Cost Estimation Data Sources

The information for cost estimation can be retrieved from: Service Items (SIM) library A library that enables you to add SIM codes with associated CPT®4 code for each practice, along with prices. You can also group service items under one main number or name. SIM exception A library that enables you to charge different fees according to provider, location, and payer. Additional fees are referred to as exceptions, which can be set up and maintained through the SIM Library. Contract library A library that enables you to set up payers for the contract and indicates the reimbursement amount for the procedures. Contract exception A library that enables you to charge different fees based on the provider, location, and payer. Each additional fee is referred to as an exception to the contract and can be set up and maintained through the Contract library. After the exceptions are set up, you can assign a contract exception to providers at the provider, payer, or location level to apply the exce

Help Guide for NextGen® Enterprise PM 8

Patient Cost Estimation Workflow

The cost estimation feature enables you to use the information within the application to provide an insight into the various costs associated with the different types of care. A practice, running in a real-time system, has a valid NextGen® Eligibility Verification license and is able to communicate with the real-time server. When an eligibility transaction is run, the system receives real-time eligibility (271) transaction file as response. A practice, running in non-real-time system, does not have a valid NextGen® Eligibility Verification license and retrieves values from the local database. If you are the administrator, you must complete the following configurations in File Maintenance. Set up payers in the payer master Set up providers in the provider master Set up the pricing for service item (SIM) codes and associate SIM codes with CPT®4 codes in the SIM library You can configure the following as needed and are not mandatory. Set up sliding fee schedules in the sliding fee schedul

Help Guide for NextGen® Enterprise PM 8

Estimating Patient Cost

In NextGen® Enterprise PM, the Estimate Patient Cost window enables you to specify the inputs required for calculating the patient and insurance responsibility amounts for services planned or rendered. You can initiate cost estimation from: The People Lookup window for a person. The Patient Lookup window for a patient. The Appointment Lookup window or the appointment book for an appointment or event. The Encounter Lookup window or the Encounters tab on the Patient Chart window for an encounter. The Estimation Results in the Clinical History/Notes tab on the Patient Chart window. When you initiate the cost estimation, the Estimate Patient Cost window opens: Every time you specify and submit data on the Estimate Patient Cost window, a new cost estimation record will be created with a unique cost estimation ID. Multiple cost estimates can be created for one person, patient, appointment, or encounter. Estimate Patient Cost Fields Details are provided for the fields that define the distribu

Help Guide for NextGen® Enterprise PM 8

Estimation Results in Patient Charts

On the Clinical History/Notes tab in a patient's chart, you can select Topics > Estimation Results . Estimation Results displays the cost estimates done for the patient. When a chart is created for a person and the person becomes a patient in the practice, the patient's completed estimates as well as the newly submitted estimates are displayed in the estimation results. Note: The estimation results do not display the estimates for a person without a chart. The estimation results display the following cost estimation details. Estimate Date Cost Estimate ID Service Date Payer Name/Self Pay Service Type Service Item Estimate Charge Estimate Allowed Estimate Patient Amount Patient Agrees To Pay Patient Paid Amount Event Encounter Status Created By Create or Open Cost Estimations from Estimation Results You can create or open a cost estimate from the estimation results in chart of a patient. Parent topic: Pre-Services Cost Estimation

Help Guide for NextGen® Enterprise PM 8

Sliding Fee in Cost Estimation

The sliding fee program offers differential pricing with adjustments based on the annual income and family size of a patient or person. Sliding fee schedules are attached to a patient or person or a specific encounter or chart in NextGen® Enterprise PM. When you attach a sliding fee schedule to an encounter, a percentage of the estimated amount specified on the Estimate Patient Cost window is automatically adjusted. In cost estimation, a patient or person eligible for sliding fee adjustments can only use the self-pay mode of payment. In NextGen® Enterprise PM, you can do the following: Attach sliding fee schedules at the chart level or encounter level for a person or patient. Note: The system does not combine encounter level and chart level sliding fees while judging which to apply. Encounter level sliding fee always take precedence over chart level sliding fee. Apply multiple sliding fee schedules at an encounter level or chart level for a person or patient. Note: When you add multipl

Help Guide for NextGen® Enterprise PM 8

Multiple Procedure Discounting in Cost Estimation

Multiple procedure discounting refers to the payment reduction applied to the allowed amount if the rendering provider performs multiple procedures on a single patient. You can configure the percentage of reduction on the allowed amount in a particular sequence of the procedure in the File Maintenance contract library. Set Up Multiple Procedure Discount You can set the percentage of reduction in the allowed amount in a particular sequence in the contract library from File Maintenance. Multiple Surgery Discounting The allowed amount is reduced for CPT®4 codes enabled with multiple surgery discounts. The discount is calculated in conjunction with the sequence of CPT®4 codes and the corresponding modifier percentage on the fee schedule. Endoscopy Discounting Multiple procedure discounts for endoscopy work in conjunction with the multiple procedure discount and base CPT®4 code fields on the Fee Schedule tab. Scenarios - Determining Allowed Amount The system uses a hierarchy to compare CPT®

Reimbursements and Discounts in Cost Estimation

Recommendations

Cost Estimation Data Sources

Patient Cost Estimation Workflow

Estimating Patient Cost

Estimation Results in Patient Charts

Sliding Fee in Cost Estimation

Multiple Procedure Discounting in Cost Estimation

Cost Estimation Data Sources

Patient Cost Estimation Workflow

Estimating Patient Cost

Estimation Results in Patient Charts

Sliding Fee in Cost Estimation

Multiple Procedure Discounting in Cost Estimation