Understanding Insurance Tags, Patient Tags, and Pricelists

This guide provides a detailed explanation of how insurance tags, patient pays tags, and pricelists function within the service database and how they contribute to the overall pricing structure during a sale. It's imperative you understand this before adding any Insurance Tags, Patient Tags, or Pricelists of your own as it can affect the overall pricing of a sale.

Key Components

1. Patient Pays Tags

• Definition: Tags that specify what the patient directly pays for services or products.

  Examples of Items Covered:

  • Eye exams
  • Retinal imaging
  • Contact lenses

  • Other diagnostic or procedural services

    Impact on Pricing:

  • These tags directly influence the "Patient Pays" section of the sale. The items in the tags listed will have the patient pay for it.

Insurance:

• An insurance company will be linked with the Patient Pays Tag which influences what the Patient has to pay depending on what insurance they have.

2. Insurance Tags

• Definition: Tags that define what insurance covers for specific products or services.

  Examples of Items Covered:

  • Type of lenses (e.g., single vision, progressive lenses)
  • Lens treatments (e.g., UV protection, scratch-resistant coating)

  • Premium tiers (e.g., progressive premium lenses)

    Impact on Pricing:

  • These tags influence the "Insurance Pays" portion of the sale. Depending on the patient’s eligibility and coverage, these tags dictate how much the insurance company reimburses or contributes towards the total cost.
  • This is done with the CPT tag that is applied onto an item which the item will have.
  • Modifiers also add an extra degree of separation from different insurance tags.

3. Pricelists

• Definition: The set of prices defined by specific sources or vendors.

  Examples of Pricelists:

  • "UT Spectera Lab Choice"

  • "Insight 202 FF (USD)"

    Purpose:

  • Serves as the foundation for product pricing.

  • Each pricelist may have variations in pricing based on the source or vendor selected.

    Impact on Pricing:

  • The pricelist determines the base price of products or services before any tags (insurance or patient pays) are applied.

How These Components Interact in a Sale

When creating a sale, the system combines the selected Patient Pays Tags, Insurance Tags, and Pricelists to calculate the final pricing structure. Below is an explanation of how each element influences the process:

1. Pricelist Selection:
   • The sale begins by selecting a pricelist (e.g., "Insight 202 FF").

   • This pricelist establishes the baseline price for products and services.

     Adding Insurance Tags:

   • Insurance tags are applied to the sale to determine coverage for eligible items.

   • For example, the insurance tag "v2523" may cover certain lenses or treatments, influencing how much insurance will pay.

     Applying Patient Pays Tags:

   • Tags for items like eye exams or retinal imaging are added to reflect what the patient is responsible for paying.

   • These tags adjust the patient’s total due based on selected services or products.

     Final Price Calculation:

   • The system calculates the total cost by combining the pricelist base price, insurance contributions, and patient payments.
   • Discounts, taxes, or other allowances may also be factored into this calculation.

Example Breakdown (Referencing Sale Screen)

• Patient Information:
  • Patient: Richard Eyemed
  • Insurance: EyeMed

  • Pricelist: Insight 202 FF (USD)

    Insurance Tag: v2523

    Product Details:

    • Contact Lens (Ultra 6pk):
      • Base Price (from Pricelist): $45.00 per pack
      • Quantity: 4 (2 packs x 2 items each)
      • Patient Pays Total: $27.00 ($13.50 for each pack x 2)
      • Insurance Pays Total: $0.00 (if not covered)
  • Calculation:
    • Base Price: $180.00 (4 packs at $45.00 each)
    • Patient Pays: $27.00 (4 packs at $13.50 each)
    • Insurance Pays: $0.00 (if not covered by insurance tag)
    • Tax: $27.00 (15% of $180.00)
    • Final Total: $207.00 (adjusted by applicable discounts or taxes)

Troubleshooting Common Issues

1. Price Discrepancies:
   • Ensure the correct pricelist is selected.

   • Verify the insurance and patient pays tags are accurately applied.

     Broken Price Calculations:

   • Check for missing or incorrect tags.

   • Review the eligibility setup in the authorization process.

     Incorrect Insurance Contributions:

   • Confirm the insurance tag corresponds to the patient’s plan and coverage.
   • Double-check any allowances or caps imposed by the insurance policy.