Insurance Setup and Management Fundamentals

Managing a patient’s insurance, including policy details, remaining benefits, expected insurance, and claims, can feel overwhelming. When everything is set up correctly from the start, insurance management becomes much more efficient and predictable. This article outlines best practices to help you maintain clean data and streamline your workflows.

Policy Holders and Employer Policies

Once a policy holder is linked to an employer policy, this relationship should remain intact, similar to how an insurance card represents a fixed relationship between subscriber and plan.

• If a patient’s insurance changes, do not overwrite or modify the existing policy holder and employer policy relationship. Instead, remove the policy holder from the patient’s chart by choosing Change Policy Holder. Create a new policy holder record and link it to the appropriate new employer policy. If the employer policy does not exist, create a new employer policy. If the patient is not getting new insurance, choose Clear Policy Holder.
• This approach ensures historical accuracy and prevents claim or reporting issues.

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Change an Employer Policy

Adding a Policy Holder

Add an Employer Policy

Assign Primary and Secondary Insurance

Financial Contracts

Insurance setup directly impacts how claims are generated, so it is critical that contracts are configured correctly.

• Work with your financial coordinator to confirm that contracts with assignment are recorded accurately. The Amount column, which is the first column, should reflect what insurance needs to see. This includes the initial fee, the number of monthly payments aligned with the minimum treatment months, and the total contract value.
• These contract values work together with employer policy details such as benefit percentage, insurance payment frequency, claim frequency, and remaining benefit.
• All of these factors influence how claims populate in the Claims Matrix.

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Create a Contract With Insurance

Create a Billing Only Contract

Create a Paid in Full Contract with Insurance

Claim Management

Regularly review open claims in the Claims Matrix and match them with corresponding insurance payments whenever possible. Close or void claims that are no longer valid and avoid leaving outdated or uncollectible claims open.

• To document changes, right-click a claim and select Edit Claim. Add an internal note explaining why the claim was closed or voided.
• Keep claims accurate by updating the Next Expected Claim Date to ensure timely claim generation. Verify that the insurance payment frequency matches the employer policy and adjust employer policy details if discrepancies are found, such as the payment percentage.
• When benefits are exhausted, uncheck Make Claims Automatically in the Insurance tab, remove the Next Claim Date, and close any open claims tied to that policy.

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Claims Matrix FAQs

Stop Generating Claims

Voiding Claims in Bulk

Posting an Insurance Payment

Post an Insurance Payment for Multiple Patients

Process an Insurance Credit Card with TopsPay

eFile a Claim in Tops