This guide has been written to help you troubleshoot issues with incorrect patient/insurance portions in your MacPractice patient ledgers.

One of the first things you will need to check is whether you are using Insurance Estimating or not. Portion calculation and behavior is entirely different with Insurance Estimating on than off. If you do not know whether you are using Insurance Estimating or not, the below steps will help you.

Go to the MacPractice menu and select Preferences. Select Insurance in the sidebar. On the General tab, one of the first preferences is labeled Use Insurance Estimating. This controls whether Insurance Estimating is currently active. If this checkbox is not checked, however, it doesn't necessarily mean that Insurance Estimating has never been used.

If this preference is turned on for any computer, click here to use the Insurance Estimating troubleshooting guide.

If you ever see any charges that have a split portion, with amounts in both the insurance and patient portion, it is possible that Insurance Estimating was on when the charges were entered. Check if the charges have applied to the copay, or if payment was ever entered and then deleted, however, as this will also split the portion. Continue reading below to troubleshoot incorrect portions with Insurance Estimating disabled.

With Insurance Estimating disabled, portion breakdowns are controlled entirely by the status of the insurance claim(s) tied to the charges. A patient with no insurance will only have a patient portion. Once a charge has been entered, the charge balance will almost always be entirely in the patient or insurance portions. Copays are the only feature that could potentially break an amount into both patient and insurance portions when Insurance Estimating is disabled.

Once charges are initially entered, they are automatically entirely in the patient portion. Once a claim has been created, the entire portion moves to the insurance portion and will generally stay there until payment has been applied. Once payment has been applied, and the claim has been closed, the remaining unpaid amount will move to the patient portion, unless secondary or tertiary claims have been created.

Usually MacPractice users create insurance claims immediately after charges have been entered, to ensure that the portion moves to the insurance portion right away. Even if users use the New Claims manager to create claims instead of creating them when entering charges, this is usually done on the same day charges are entered, to prevent incorrect portions. 

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Portions that appear to be incorrect should be addressed as soon as possible. This will ensure that financial reports and statements are correct. If you determine that any of your insurance and patient portion breakdowns are incorrect, this guide will help you troubleshoot to determine where the source of the issue is. Troubleshooting issues with incorrect portions usually involves checking the insurance claim status.

Using The Prior Authorization:

If there is too large of a patient portion:

• Check to be sure that all procedures in question have an insurance claim created for them, or that they appear on all claims. A quick way to determine this is done by highlighting the claim and seeing what is tied to it, by either using the View Options menu (located in the upper right corner of the MacPractice ledger) and selecting Related Transactions or by simply visually checking what is tied with the yellow highlights. If you printed a paper claim form and saved the pdf to the database, you can also check the pdf copy to verify which procedures were printed on the claim. For electronic claims you can do something similar by double clicking on the claim in the ledger, then in the bottom left area in the eClaims ability, expand the Procedures node to determine which codes are associated to the claim. If you find that a procedure was indeed missing from a claim, you will need to create a new claim for the procedure in question, or delete the original claim and start over, provided the claim hasn't been sent yet.

• Check if the charge has a copay amount associated to it in the Charge window. If the Charge Copay checkbox is checked, any amount entered in the Patient > Insurance > Copay area will be associated to the charge as a copay amount. This copay amount will always stay in the patient portion until it is paid, regardless of claim status. The copay amount can be overridden in the Charge window, if needed.

• Check that the status of the claim(s) associated to the charge(s) is/are open. Any status other than Paid/Closed or Archived is considered open. If you find your claim is closed, you may open it again by first selecting the claim, then from the Other menu select a new status.

• Try toggling the status of the claim. This is done by closing the claim and re-opening it. Select the claim, go to the Other menu and select Paid/Closed, then go to the Other menu again, and set the status back to what it was previously (Invalid, Ready, Sent, Accepted or Rejected). Be sure to use the same status that the claim had before to ensure no confusion is made with rejections, denials, and so on. Some actions in the ledger may cause the portion breakdown to require refreshing, which is accomplished by toggling the status of the claim. Toggling the claim status will fix incorrect portions most of the time, provided Insurance Estimating is not in use. The following is an example of what could possibly require a simple claim status toggle.

Example: If a claim was created, then an insurance payment was posted to all procedures on the claim, this will mark the claim as Paid/Closed and send any remaining portion to the patient. If the payment was then deleted, the claim will automatically be reopened, and the insurance payment amount tied to the charges will be sent back to the insurance portion, but not the unpaid amount that was in the patient portion. This amount will stay in the patient portion until the claim is refreshed. This is just one example of many possible causes that would require the claim status to be toggled.

• Check either Carrier Always Pays Provider or Accepts Assignment in the Insurance reference. Generally speaking, if you do not accept assignment with an insurance carrier MacPractice assumes the insurance payment for the procedure will go to the patient, and your office will collect payment from the patient. Because of this, if Accepts Assignment was not checked when the claim was created, the portion will remain in the patient portion. If Accepts Assignment needs to be checked, you will need to recreate your claim. If you do not accept assignment with a carrier, but you do collect payment from them, or wish the portion to move to the insurance portion, check Carrier Always Pays Provider instead. This will ensure the portion will move to the insurance portion when a claim is created, without having to have an "accepts assignment" status printed or sent on your claims.

If there is too large of an insurance portion:

• Check for outstanding claims that should not be open. You can quickly check for incorrectly open claims easily by using the View Options menu and selecting Outstanding Claims. This will display only open claims in your patient's incident. You may also decide to scroll over until you find the Status column in the ledger, at which point you can visually determine where the open claims are. Close all erroneously open claims and check your portions again.

• Try posting a $0.00 insurance payment to the claim. If closing the claim does not move the insurance portion to the patient portion, sometimes posting a $0.00 insurance payment to it will. To post this payment, you will need to reopen the claim if you closed it. To do this, highlight the claim again, then use the Other menu to choose an open status, such as Ready, Sent, or Accepted. You will then be able to enter a new insurance payment, enter a $0.00 amount, and be sure to enter the $0.00 amount in the Payment column for all procedures as well. While posting, this should automatically close the claim if all procedures are paid. If you do not post the $0.00 payment to all procedures you may have to manually close the claim again.

If none of these options help you correct your insurance/patient portions, please contact the MacPractice Support department.