What to Do When a Patient's Insurance Benefit Increases

Deciding how to handle an insurance credit or an increase in a patient's expected insurance comes down to whether the patient has an active contract or not, or how the patient wants you to apply the credit from insurance.

Common scenarios include:

• Insurance payments have exceeded the original estimate, creating a credit in Expected Insurance.
• The patient’s insurance benefits have increased.
• The patient has obtained new insurance coverage that will increase the total expected insurance amount.
• The patient has an insurance credit that you need to move to the patient's balance.

If the Contract is Active

If the contract is active, updating the Expected Insurance within the contract worksheet ensures the patient’s financial information remains accurate going forward.

Follow the steps below to reduce the patient's future copay amounts, and apply the increase in insurance benefit or the accumulated insurance credit to the expected insurance balance.

1. Open the patient's chart; go to View > Patient Info or press Command I.
2. Click on the Contracts/Ledgers tab.
3. Double-click on the contract you wish to edit.
4. In our example, patient Jules Jones started with an insurance benefit of $1000. She now has a $1500 benefit. We now need the Expected Insurance and the Calculated Insurance to show $1500 in her contract worksheet:

5. Talk to the patient/responsible party and figure out if they will pay the same monthly payment amount for fewer months OR pay a smaller amount each month now that their insurance benefit has increased.
6. Jules's mom decided that she will decrease her monthly payments from $250.00 to $230.00.
7. DO NOT use Action > Change Expected Insurance.
8. Instead, in the contract worksheet, double click on the next copay charge and edit it to the new copay amount. DO NOT change the amounts in the middle column.
9. Edit the remaining copay amounts, moving down the list carefully. Remember not to touch the middle column figures!
10. As you work, you will see the lower right Calculated Insurance amount increasing - that's a good sign!
11. Keep going until it the Calculated Insurance reaches the AMOUNT YOU WILL ACTUALLY RECEIVE FROM INSURANCE.

12. In Jules's case, we had to make the last copay charge $210.00 to make the Calculated Insurance reflect as $1500. Note how the Contract Total remains at its original $6580. This is very important!
13. When you are satisfied with your changes, click Record Contract.
14. This window will come up; don't be scared! This is Tops asking you if you meant to change the expected/calculated insurance, and if you want the Expected Insurance on the top left to change to match your new Calculated Insurance number. Go ahead and click Change.

15. You will now notice that the blue snapshot to the left of the patient's picture reflects the new expected insurance amount. Good job!

If the Contract is No Longer Active

If the patient’s contract is no longer active, or the patient would like to apply an insurance credit toward their current balance, you won't be able to adjust the contract worksheet. Follow these steps:

Adjust the Expected Insurance

1. Navigate to Action>Change Expected Insurance
2. If the patient has an insurance credit:
   • Increase the Expected Insurance amount by the credit amount, or by the portion of the credit you want to apply to the patient’s Due Now balance.
   • Alternatively, you can set the Expected Insurance amount to $0 to apply the entire available credit.
   • This action transfers the selected credit amount from Expected Insurance to the patient’s Due Now balance.
3. If the patient has obtained new insurance coverage and expects future insurance payments:
   • Wait until insurance payments are received and the Expected Insurance balance reflects a credit.
   • Once a credit exists in Expected Insurance, follow the steps above to transfer the credit to the patient’s account balance.