Insurance Estimating provides an estimated amount an insurance company might pay toward a charge based on the patient's insurance plan. With Insurance Estimating, an estimated patient and insurance portion are made as the charge is entered. Without Insurance Estimating, the entire amount of a procedure will be added to the insurance portion once a claim is created and the remaining balance will only be moved to the patient portion after the claim has been paid or closed.

As Insurance Estimating is configured, coverages, allowed amounts, flat rates, and so on are added to the Insurance Company reference by plan, where the insurance percentage is associated to a Procedure Type.

Insurance Estimating should only be considered an estimate that can only be as accurate as the information entered within MacPractice. An insurance carrier may not pay as estimated. For the most accurate estimates, understand the Insurance Estimating Formulas through which estimates are calculated and the unique fields within the Insurance Company Reference, from which the formula variables are derived.

Formulas

MacPractice calculates the portions of charges based on the following formulas:

[Fee] - [Allowed] = [Write Off]If you participate with the plan, the estimated write-off will stay in the Insurance Portion until the insurance payment is entered or the claim is manually closed. If Participate is not checked in the insurance plan reference, the estimated write-off will be placed in the patient portion.

The calculation for the insurance portion can vary, depending on whether you have Flat Rate Coverage enabled for the selected code.

For percentage coverage:
([Allowed Amount] - [Deductible] - [Copay]) x [Insurance %] = [Insurance Portion (up to the patient's remaining coverage)]
For flat rate coverage:
[Allowed Amount] - [Deductible] - [Copay] = [Insurance Portion (up to the patient's remaining coverage or the flat rate, whichever is less)]

When using plans, information entered within the plan overrides the Company Info and Provider IDs tabs whenever the plan is associated to the account.

If you are using EOB columns to send secondary eClaims, the disallowed amount in the insurance payment window is calculated based on the following formula:

[Fee] - [Paid] - [Sum of the EOB Columns Deductible, Coinsurance and Copay] = [Disallowed amount]

Any remaining Disallowed amount requires a corresponding Reason Code. If the Disallowed amount is zero, no additional Reason Code is required.

Deductible and Copay amounts will be added to the Patient Portion.

If any variables are not correctly set up, delete the charge and reenter it after corrections are made to recalculate the insurance estimate. You can also recalculate the estimate by checking and unchecking the Patient Responsible checkbox in the charge window if a payment has not been applied to the charge.

Secondary Insurance Estimating FormulasSecondary insurance coverage is calculated differently depending on whether the Coordination with Other Carriers is set to Standard or Non-Duplicating:

Standard Coverage = Secondary allowed (x) Insurance % (-) Secondary Deductible (=) Secondary Insurance Portion (up to the Secondary Remaining Coverage and/or Unpaid Amount)

Non-Duplicating Coverage = Secondary allowed (x) Insurance % (-) Secondary Deductible (=) Secondary Insurance Portion (+) Primary Insurance Portion (up to the Secondary Remaining Coverage, and/or Unpaid Amount)