Pre-requisites:

• Important: Registration MUST be done for the same patient separately for each Employer and for all non-Employer visits if a clinic sees patients for both Employer visits and non-Employer visits.
• There should be proper Encounter Types defined in Settings > Configuration > Encounter Types on the EMR side. These Encounter Types should be marked as "Billed To" = "Employer" from the dropdown list.
• All Employers should be defined in Settings > Configuration > Employer Master.
• An appropriate Fee Schedule 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 with each Employer. Otherwise, the default will be considered as U&C.
• There should be a valid Employer associated with the patient from the Employer Master by going to the Patient Registration Screen > Contacts Tab. The Employer can be selected using autocomplete or by selecting from the search binocular.
•  If an Employer is typed in, and not selected from the Employer Master, it is accepted and indicated by the words "Unknown Employer" shown in a black and bold font next to the Clear hyperlink.
• A new Employer can be added from the Contacts tab of the Patient Registration screen using  button, but it is recommended to add only those employers in the Employer Master that 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 an Encounter Type with "Billed To" marked as "Employer" for a patient who has an Employer selected from the Employer Master, the appointment passes all validations and is scheduled.
• If the patient does not have an Employer Name associated from the Employer Master (i.e., the Employer Name field on the Patient >> Registration >> Contacts Tab is either blank or typed in), an appropriate alert is shown and the appointment is not allowed to be scheduled or marked "Arrived".
• If an encounter is directly created from the Start Encounter Screen, without scheduling an appointment, there are similar validations for the Encounter Type and the patient's employer. Even if the Encounter Type is changed from a Non-Employer Billing Encounter Type to an Employer Type Encounter Type, proper validation for the Employer is performed.
• The Encounter Type and Employer Name are carried forward to the Employer Claim once it is created on the EMR side.

Creating an Employer claim:

Creation of an Employer claim from the EMR side

An Employer claim is created from the EMR side only if:

1. The patient has a valid Employer selected from the Employer Master, and
2. The Encounter Type used for the appointment and encounter has "Bill To" set as "Employer".

Default Info on Claims >> Edit screen

When an Employer claim is created, it will show:

1. The "Bill to Employer" checkbox automatically checked.
2. The name of the "Employer" displayed in a bold and red font to easily identify these claims.
4. The Enc Type field displayed on the button
   with the proper Enc Type with "Billed To" set as "Employer" populated.
   • The "Send" button disabled.

For creating an Employer claim from the Claims >> New screen directly:

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

 Other important aspects about Employer Claims

1. The Primary Insurance dropdown displays the name: Self Pay - Employer.
2. Copay, Deductible, and Visit Fee cannot be collected for an Employer Claim. Only an Advance can be collected on the Co-pay screen pop-up.
   
   Warning: Even if an Advance is allowed to be collected for Employer claims, it should not be collected. This Advance, if collected, will continue to lie in the Advance bucket until it is moved to another record of this patient for non-Employer visits using the Xfer PatCredit feature.
   
3. The fees for charge codes are pulled from the Fee Schedule which is associated with the Employer entry in the Employer Master. There is a new field in the Employer Master called "Fee Schedule Type" to associate the appropriate Fee Schedule Type with it.
4. The amount is billed to the Employer. Hence, it is shown under the "Employer" column with the 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 always has the "Send" button disabled.
6. When an invoice is generated, the claim gets processed and an Invoice number is automatically assigned to the claim and is displayed on the claim. This Invoice number is displayed right after the "Sent Date" field on the claim in a bold and black font.
7. Next time, when an Invoice for the same Employer and the same Encounter Type for a qualified date range is generated, this claim will not be considered, as it is billed and associated with an Invoice number.

Validations on the Claim Screen:

• If a claim is an Employer Claim and the "Bill to Employer" checkbox is checked, but there is no Encounter Type selected from the dropdown on the button and the claim is marked "Ready to Send", it displays the following alert message and does not allow processing the claim until a 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 an Employer Claim and the "Bill to Employer" checkbox is checked, but there is no Employer displayed on the claim in red, such a claim will not be allowed to be processed until a valid employer from the Employer Master is associated with the patient record on the Contacts tab and displayed on the claim.
  Even if the Employer is typed in, it shows "Unknown Employer" on Patient Details and that name is not displayed on the Claim screen. In this case as well, the employer should be selected from the Employer Master and saved on the Patient Details screen, and it will then be displayed in red on the claim when marked "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 an Employer Claim and the "Bill to Employer" checkbox is checked, but there is no Encounter Type selected from the dropdown on the "I" button and the claim is marked "Ready to Send", it displays the following alert message and does not allow processing the claim until a 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".
• The Copay Amt must be zero for a Bill to Employer claim.
• The Deductible Amt must be zero for a Bill to Employer claim.
• The Visit Amt must be zero for a Bill to Employer claim.
• The "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 an individual claim for each employee but by generating an invoice every month. There can be various types of visits like Firefighter Physical, Audio, DOT, and PPD for which multiple patients were seen. For each such type of visit for each employer, one invoice has to be generated. For example, 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 with one Encounter Type, as soon as Encounter Type-based invoices are generated, all unprocessed claims which are marked as "Ready to Send" are automatically considered for the invoice for that Encounter Type, automatically get marked as Billed, and the Invoice Number gets automatically assigned to the claim. Each Invoice Number has a prefix of the Encounter Type code for which it is created.

Note: Once a claim is marked "Billed", and an Invoice number is associated with it, that claim will never be considered again in any invoice for the same employer for the same Encounter Type for the qualified Date Range.

The Claims > Emp Invoice screen has mainly two options with radio buttons:

1. Display: which allows selecting the already generated invoices and displaying their details.
2. Create Invoice: which creates invoices for those claims per Employer per Encounter Type which were not considered in previous invoices, and hence do not have an Invoice number assigned.

Display Option: The display option when chosen enables the binocular which displays all invoices generated so far for each Employer, associated Encounter Type, Invoice Number, and the Date the Invoice was generated. Any invoice chosen from the Display list is displayed in a pop-up for viewing and printing.
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 the invoice details are generated by the program.

The generated invoices are saved in the Settings > Configuration > Download Files option as a single PDF. These can be downloaded from the Download Files option and then printed and sent to the respective Employer. If the generated invoices have to be viewed from the Employer Invoice screen as they are being generated, the checkbox "Show Generated Invoice" must be checked. This will open a pop-up window where all the generated invoices can be viewed.
The generated invoice shows the clinic's details at 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, and the invoice generation date, followed by the details for that period. The details include the Date of Service, Billed Procedure Code, Name of the charge code, Quantity or Units Billed, and the Billed Amount. After all procedure codes for that visit are printed, the name of the patient and the total amount billed are printed. The footer can show a 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. The employer may or may not send a 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 the "Add New" button. On the blank Employer Receipt, the field "Received From" displays the option "Employer" already selected. Check details and the Check Amount can be entered in the "Pay Mode" and "Received Amt" pop-up fields respectively. The name of the employer must be selected in the "Employer" field either by typing and selecting the employer from the autocomplete list or by using the search binocular.


Since the billing to each employer is invoice-based, the payments are received from the employer per invoice. The "Save" button must be clicked to enable the "Select Invoice" binocular search.  The Select Invoice search shows all the invoices for which the payment is still outstanding. Even if a partial payment has been received for some claims and some charge codes of an invoice, it will still be listed. The details shown are the 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 the selected claim are shown. The allocated amount for each claim is also allocated automatically to each charge code and 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 a change to the "Allocated Amt" and "Received Amt" for the voucher.  If the 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 the same as "Received Amt" and the "Remaining Amount" is zero, the Employer Invoice can be posted by selecting the "Ready to Post" checkbox.

Difference Between Patient Receipt and Employer Receipt Functionality:
Unlike the Advance Bucket for a Patient Receipt, no such bucket exists for an Employer Advance. Therefore:

• An Employer Receipt cannot have a Remaining Amount, and it cannot be moved to the Employer Advance.
• An Employer Receipt cannot be posted with a "Received Amt" without selecting an invoice, because the "Remaining Amt" cannot be moved to the Employer Advance.
• An Employer Invoice cannot be posted with a zero "Received Amt" and allocating an Employer Advance to an invoice, as the Employer Advance concept is not supported.

Note: If a claim is deleted from the claims list and is needed back, the entire invoice has to be reselected. Therefore, there is no need to explicitly delete the claims for which no payment was received. They will be automatically dropped off upon posting.

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 two canned reports under "Reports > Tabular" to get additional information related to employer billing.

Employer Aging Report:
The screen "Emp Aging" allows searching for the employers for whom the aging report is to be generated. The aging report can be generated based on either the Responsibility Date (i.e., when the responsibility of that employer was generated, which is the Invoice Creation Date) or based on the DOS (i.e., Date of Service).

There are three 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 the Claim ID, Invoice Date, Patient Name, Sent Date, Billed Amount, aging columns, and the Total Outstanding Amount. It also shows the totals for each amount column per employer.

3. Employer - Claim - Charge Details:
This report displays employer-wise, invoice-wise, claim-wise, and charge code-wise details, including the Patient Name, charge code, Billed Amount, Outstanding Amount, and the number of days since it has been outstanding. Here aging buckets are not shown, but the "Days" column shows the number of days since that charge code has been outstanding.

The "Layout" button in the list of parameters for generating the Employer Invoice allows selecting the appropriate aging buckets to be seen in the 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 365+ bucket will be automatically shown in the output aging report.

Tabular Reports:

1. EMP01: Employer Billing Report - Itemized Invoice List per Employer
This report shows the Itemized Invoice List per Employer. For the selected date range and employers, all billed invoices, their dates, the Enc Type in the description, and the Billed Amount are shown.

Generally, one invoice per Encounter Type or Visit Type is generated for an Employer from the Employer Invoice screen. This is a detailed charge code-wise invoice. There are several such invoices generated. This report shows one entry per invoice for all such invoices generated per employer in a period for quick reference along with the amount billed.

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

Claims Outstanding List, Claims Center, and Charges Center:
To supplement these reports, there are filter criteria present on the Claims > Outstanding, Claims Center, and Charges Center pages, such as "Employer Responsibility" and "Employer Name".


Billing Home Page:
The Total Employer Outstanding Amount is displayed in the Outstanding table on the Billing Home Page instead of the Total Outstanding Amount field as soon as there is an Employer Outstanding amount present.