Pre-requisites:

• Important: Registration MUST be done for same patient separately for each Employer and for all Non-Employer visits if a clinic sees patients for Employer visits and non-Employer visits.
• There should be proper Encounter types defined in Settings>Configuration>Encounter Types from EMR side. These Encounter Types should be marked as ‘Billed To’ = ‘Employer’ from Drop Down list.
• All Employers should be defined in Settings>Configuration>Employer Master.
• Appropriate Fee Scheddule should be defined for Employer Billing. If no specific Fee Schedule is needed, U&C will be considered.
• The Type of defined Fee Schedule should be associated to each Employer. Else, default will be considered as U&C.
• There should be valid Employer associated to Patient from Employer Master by going to Patient Registration Screen>Contact Tab. Employer can be selected using Auto complete or selecting from Search binocular.
•  If Employer is typed in, and not selected from Employer Master, it is accepted and indicated by words ‘Unknown Employer’ shown in black and bold font next to Clear hyperlink.
• New Employer can be added from Contacts tab of Patient Registration screen using  button but it is recommended to add only those employers in Employer Master which are used for Employer Billing. For all other patients, just type the Employer Name.

Scheduling Appointments and Creating Encounters for Employer Patients:

• When an appointment is scheduled with Enc Type with ‘Billed To’ marked as ‘Employer’ for a patient who has Employer selected from Employer Master, the appointment passes all validations and is scheduled.
• If the Patient does not have Employer Name associated from Employer Master i.e Employer Name field on Patient >> Registration >> Contacts Tab is either blank or typed in, appropriate alert is shown and Appointment is not allowed to be scheduled or marked ‘Arrived’.
• If an Encounter is directly created from Start Encounter Screen, without scheduling appointment, there are similar validations for Enc Type and Patient’s employer. Even if the Encounter type is changed from Non-Employer Billing Enc type to Employer Type Encounter type, proper validation for Employer is done.
• The Enc type and Employer name is carried forward to Employer Claim once it is created from EMR side.

Creating an Employer claim:

Creation of Employer claim from EMR side

An Employer claim is created from EMR side only if

1. The patient has  valid Employer selected from Employer master and
2. The Encounter Type used for Appointment and Encounter should have ‘Bill To’ set as ‘Employer'.

Default Info on Claims >> Edit screen

When an Employer claim is created, it will show

1. Checkbox ‘Bill to Employer’ automatically checked.
2. Name of the ‘Employer’ displayed in bold and red color font to easily identify these claims.
4. Enc Type field displayed on button
   with proper Enc type with ‘Billed To’ set as ‘Employer’ populated.
   • Button ‘Send’ disabled.

For creating a Employer claim from Claims>>New screen directly:

1. Create a regular claim.
2. On Claims>Edit screen, the checkbox ‘Bill to Employer’ should be explicitly checked.
3. The patient’s Employer selected from Employer Master automatically populates in Red and Bold font.
4. The Enc Type list shows the Encounter types where ‘Bill To’ has been marked as ‘Employer’.
5. Appropriate Encounter type must be selected from this list on the created claim’s button.

 Other important aspects about Employer Claims

1. Primary Insurance dropdown displays name:  Self Pay – Employer.
2. Copay, Deductible, Visit Fee cannot be collected for Employer Claim. Only Advance can be collected on Co-pay screen pop-up.
   
   Warning: Even if Advance is allowed to be collected for Employer claims, it should not be collected. This Advance if collected will continue to be lying in Advance bucket till it is moved to other record of this patient for Non-Employer visits using feature: Xfer PatCredit.
   
3. The fees for charge codes are pulled from Fee Schedule which is associated to the Employer entry on Employer Master. There is a new field on Employer Master called ‘Fee Schedule Type’ to associate the appropriate Fee Schedule Type to it.
4. The amount is billed to Employer. Hence it is shown under column ‘Employer’ with Checkbox next to it checked. The ‘Bill Ins’ field remains grayed out.
5. The Employer claim can be manually marked as ‘Ready to Send’ but cannot be processed manually. Therefore, the Employer claim has button ‘send’ always disabled.
6. When an invoice is generated, the Claim gets processed and Invoice number is automatically assigned to the claim and is displayed on the claim. This Invoice no. is displayed right after 'Sent Date' field on claim in bold and black font.
7. Next time, when an Invoice for the same Employer for same Encounter type for qualified date range is generated, this claim will not be considered as it is billed and associated with Invoice number.

Validations on Claim Screen:

• If a claim is Employer Claim and Checkbox ‘Bill to Employer’ is checked, but there is no Encounter Type selected from dropdown on button  and claim is marked ‘Ready to Send’, it gives following alert message and does not allow processing the claim till valid Enc Type is selected.
  The alert message displayed is: ‘Please select Enc Type from 'I' button for Employer claim or uncheck Bill to employer checkbox’.
• If a claim is Employer Claim and Checkbox ‘Bill to Employer’ is checked, but there is no Employer displayed on claim in red, such a claim will not be allowed to be processed till valid employer from Employer master is associated to the patient record on Contacts tab and displayed on claim.
  Even if the Employer is typed in, it shows ‘Unknown Employer ‘ on Patient Details and that name is not displayed on Claim screen. In such a case too, the employer should be selected from Employer Master and saved on Patient Details screen and it will be then displayed in red on claim on ‘Ready to send’.
  The alert message shown is: “Please add valid Employer to Patient Details or Uncheck ‘Bill to Employer’ checkbox”.
  
• If a claim is Employer Claim and Checkbox ‘Bill to Employer’ is checked, but there is no Encounter Type selected from dropdown on ‘I’ button and claim is marked Ready to Send, it gives following alert message and does not allow processing the claim till valid Enc Type is selected.
  The alert message displayed is: ‘Please select Enc Type from I button for Employer claim or uncheck Bill to employer checkbox.
• Copay Amt must be zero for Bill to Employer Claim.
• Deductible Amt must be zero for Bill to Employer Claim.
• Visit Amt must be zero for Bill to Employer Claim.
• ‘CMS’ flag: Discount Amt and % fields are disabled.

Process an Employer claim – Generate Employer Invoice:

A new menu option ‘Claims> Emp Invoice’ has been introduced to generate Employer Invoices. Generally, the Employer is billed not for individual claim for each employee but by generating an invoice every month. There can be various types of visits like Fire Fighter Physical, Audio, DOT, PPD for which multiple patients were seen. For each such type of visit for each employer, one Invoice has to be generated. For ex: If Employer A sends employees for 8 types of visits in a month, there have to be 8 Invoices generated for that employer. In PrognoCIS, these visit types are defined as Encounter types. Since each claim is associated to one Encounter type, as soon as Enc type based invoices are generated, all unprocessed claims which are marked as Ready to Send are automatically considered for Invoice for that Enc Type, automatically get marked as Billed and the Invoice Number gets automatically assigned to the claim. Each Invoice Number has a prefix of code of Enc Type for which it is created.

Note: Once a claim is marked ‘Billed’, and Invoice number is associated to it, that claim will never be considered again in any Invoice for the same employer for the same Enc Type for the qualified Date Range.

Claims> Emp Invoice screen has mainly two main options with Radio buttons:

1. Display : Which allows selecting the already generated Invoices and display their details.
2. Create Invoice: Which creates Invoice for those claims per Employer per Enc Type which were not considered in previous Invoices  and hence do not have Invoice number assigned.

Display option:The display option when chosen enables the binocular which displays all Invoices generated so far for each Employer, associated Enc Type, Invoice Number and Date the Invoice was generated. Any Invoice if chosen from the Display list is displayed in a pop-up for viewing and printing out.
Create Invoice option:An Invoice can be generated by selecting the ‘Create Invoice’ option for multiple Employers in one shot for a period of time. By default the checkbox ‘By Enc Type’ is checked so that one Invoice is generated for one encounter type for an employer. If a single combined Invoice for an Employer needs to be generated, this checkbox has to be unchecked. The ‘Select Template’ option allows selecting the template to be used for generating the Invoice. In this template, the header can be configured and Invoice details are generated by the program.

The generated invoices are saved in Settings>Configuration>Download Files option as a single PDF. These can be downloaded from the Download Files option and then printed and sent to respective Employer. If the generated Invoices have to be viewed from the Employer Invoice screen as these are being generated, the checkbox ‘Show Generated invoice’ must be checked. This would pop-up a window where all the generated invoices can be viewed.
The generated Invoice shows the clinic details on the top, the employer details to whom the Invoice has to be sent, the Encounter Type or Visit Type for which the invoice is printed, the Date Range for that Invoice, Invoice generation Date following by details for that period. The details include Date of Service, Procedure Code Billed, Name of the Charge code, Quantity or Units Billed and Billed Amt. After all Procedure codes for that Visit are printed, the Name of the Patient and Total Amount Billed is printed. The Footer can show some message or instructions to the Employer if needed.

Payment Posting - Employer Receipts per Invoice:

Once the Invoices for a period are sent to an employer, the employer generally pays in full for that Invoice. Employer may or may not send the detailed split per claim per charge code. Hence, PrognoCIS takes care of automatically allocating the check amount to all charge codes of the paid invoice. There is a new menu option added in PrognoCIS to process Employer receipts or payments called ‘Remittance>Emp Receipt’.

For generating a new Employer Receipt, click button ‘Add New’. On the blank Employer Receipt, field ‘Received From’ displays the option ‘Employer’ already selected. Check details and Check Amount can be entered in pop-up ‘Pay Mode’ and ‘Received Amt’ fields respectively. The name of the Employer must be selected in field ‘Employer’ either by typing and selecting the employer from auto complete list or using the search binocular.


Since the billing to each employer is Invoice based, the payments are received from Employer per Invoice. Button ‘save’ must be clicked to enable the binocular ‘Select Invoice’.  The Select Invoice search shows all the Invoices for which the payment is still outstanding. Even if the partial payment has been received for some claims and some charge codes of an Invoice, it will still be listed. The details shown are Invoice number, Invoice Date, Enc Type, Billed Amount and Balance Amount.

As soon as an Invoice is selected, all the claims from that Invoice are displayed in ascending order and the check amount is automatically allocated to each claim equal to the Billed Amount. The icon  ‘Show Claim Details’ when clicked, the charge code wise details for selected claim are shown. The allocated amount for each claim is also allocated automatically to each charge code and it is equal to the Billed amount for that charge code.

If the claim or charge code is partially paid, the Allocated amount on the claim or Paid Amount on the charge code can be manually changed. This results in change of ‘Allocated Amt’ and ‘Received Amt’ for the voucher.  If Balance amount for a charge row has to be written off, it can be entered in the W/Off column. Comments can also be entered in the Comments field.

Once the ‘Allocated Amt’ is same as ‘Received Amt’ and the ‘Remaining Amount’ is zero, the Employer Invoice can be posted by checking ‘Ready to Post’ checkbox.

Difference between Patient Receipt and Employer Receipt functionality:
Unlike Advance Bucket of Patient Receipt, no such bucket for Employer Advance exists. Hence,

• An Employer Receipt cannot have Remaining amount and it cannot be moved to Employer Advance.
• An Employer Receipt cannot be posted with some ‘Received Amt’ without selecting any Invoice because ‘Remaining Amt’ cannot be moved to Employer Advance.
• An Employer Invoice cannot be posted with zero ‘Received Amt’ and allocating Employer Advance to an Invoice as there is no Employer Advance concept supported.

Note: If a Claim is deleted from the claims list and is needed back, the entire Invoice has to be reselected. Hence, no need to explicitly delete the Claims for which there was no payment received. They will be automatically dropped off on Post.

Tracking Employer Billing and Payments using Reports
There is a new menu option added under Reports for tracking Employer Payment Aging called ‘Emp Aging’.

In addition to that there are 2 canned reports under ‘Reports>Tabular’ to get additional information related to Employer billing.

Employer Aging Report:
The screen ‘Emp Aging’ allows searching the Employers for whom the aging report has to be generated. The Aging report can be generated based on either Responsibility date i.e when the responsibility of that employer was generated i.e Invoice Creation Date OR based on DOS i.e. Date of Service.

There are 3 formats in which the Employer Aging report can be generated:

1. Employer Aging Summary:
This report displays each  Employer in one row and shows the total Billed amount so far, various aging buckets and their amounts and the Total Outstanding Amount from all displayed aging buckets.

2. Employer Claim Wise Aging:
This report displays one table for each employer and one claim per row with Claim ID, Invoice Date, Patient Name, Sent Date, Billed Amount, Aging columns and Total Outstanding amount. It also shows the Totals for each Amounts column per Employer.

3. Employer – Claim – Charge Details:
This report displays Employer wise, Invoice wise, Clam Wise, Charge code wise details including Patient Name, Charge code, Billed Amount, Outstanding Amount and Number of Days since it is outstanding. Here Aging buckets are not shown but ‘Days’ column will show the number of days since that charge code is outstanding.

Button ‘Layout’ in the list of parameters for generating Employer Invoice allows selecting the appropriate Aging buckets to be seen in output report.
For Example: If only two Aging Buckets 0-365 and 365+ are to be seen, the Layout will allow users to select only one bucket 0-365 and the bucket 365+ will be automatically shown in the output Aging report.

Tabular Reports:

1. EMP01:Employer Billing Report - Itemized Invoice List per Employer
This report shows Itemized Invoice List per Employer. For a selected Date Range Employers selected, all Invoices billed, their date, Enc Type in Description and Amount Billed are shown.

Generally, one Invoice per Encounter Type or Visit Type is generated for an Employer from Employer Invoice Screen. This is a detailed Charge code wise Invoice. There are several such Invoices generated. This report will show one entry per Invoice for all such Invoices generated per Employer in a period for quick reference along with amount billed.

2. EMP02:Employer Billing Report - Enc Type wise Charge Codes Billed and OS amounts
This report allows filtering the Claims billed to Employer based on Enc Type for a date range. Enc Types represents the various visit types for which the patients from each employer are seen. When this report is run, it shows quick summary of all charge codes billed per Enc type per Employer and how much is paid and outstanding amount. This data will help clinics analyze how their business with various employers is progressing and what types of visits are more common and their revenues for the chosen period.
The other details like Invoice Number, Invoice Date, Claim ID, Claim Date, Patient Name, Code, etc. gives them in depth information for analysis purposes.

Claims Outstanding list, Claims Center and Charges Center:
To supplement this report, there are filter criteria present on Claims> Outstanding, Claims Center and Charges Center like ‘Employer Responsibility’ and ‘Employer Name’.


Billing Home Page:
Total Employer Outstanding Amount is displayed in Outstanding Table on Billing Home Page instead of Total Outstanding Amount field as soon as there is some Employer Outstanding amount present.