REVENUE AND NET BALANCE CALCULATION HELP (VER 7.2.0 P
onwards)
Scenario
1:01/01/2008 Claim # 1000 – No Insurance Payment
Formula
for Revenue = Billed Charge– Financial Adj
– Contractual Adj – Withheld + Refund
– TempContAdj
|
|
Code |
Billed Charge |
Allowed |
Payment |
Capitated |
Financial Adj |
ContAdj |
TempContAdj |
Revenue |
Balance |
|
Formula |
|
|
|
|
|
|
|
(Billed Charge-Allowed) |
|
|
|
CPT1 |
99213 |
$250 |
$150 |
$0 |
Yes |
$250 |
$0 |
$0 |
$0 |
$0 |
|
CPT2 |
G0002 |
$25 |
$10 |
$0 |
No |
$0 |
$0 |
$25-$10=$15 |
$25-$15=$10 |
$10 |
|
CPT3 |
86315 |
$10 |
$5 |
$0 |
Yes |
$10 |
$0 |
$0 |
$0 |
$0 |
|
CPT4 |
J73878 |
$15 |
N/A (Hence will replace with billed charge of $15) |
$0 |
No |
$0 |
$0 |
$15-$15=$0 |
$15-$0 = $15 |
$15 |
|
Total |
|
$300 |
|
$0 |
|
$260 |
$0 |
$15 |
$25 |
$25 |
Now,
assuming that the capitation program is run and the Financial adj of $260 (due to CPT1 and CPT3 = $250+$10) is applied
based on the capitated CPTs
the New column (TempContAdj) is
Billed – Allowed: $25 - $10 = $15 (note: it only applies to the
line which has allowed and is not capitated. Also
when there is no allowed, billed = allowed amount so for CPT 4, the new column
value is $15 - $15 = 0)
So
revenue = $300 - $260 - $15
Revenue = $25
Withheld = $0
Refund = $0
Calculated Net aging Balance = Billed Charge– Ins Payment-Financial Adj –
Contractual Adj – Withheld + Refund – TempContAdj
= $300 - $0 - $260 - $0 - $0 +0 - $15 = $25
Scenario
2: 01/30/08 Claims #1000 receives an Ins Payment
Code
Charge
Allowed
Payment Capitated
Writeoff Cont Adj
Temp Adj
Line Item Revenue
CPT1
99213
$250
$150
$0
Yes
$250
0
0
$0
CPT2
G0002
$25
$10
$10
No
15
0
$10
CPT3
86315
$10
$5
$0
Yes
$10
0
0
$0
CPT4
J73878
$15
None
$10
No
5
0
$10
|
|
Code |
Billed Charge |
Allowed |
Payment |
Capitated |
Financial Adj |
ContAdj |
TempContAdj |
Revenue |
Balance |
|
Formula |
|
|
|
|
|
|
|
(Billed Charge-Allowed) |
|
|
|
CPT1 |
99213 |
$250 |
$150 |
$0 |
Yes |
$250 |
$0 |
$0 |
$0 |
$0 |
|
CPT2 |
G0002 |
$25 |
$10 |
$10 |
No |
$0 |
$15 |
$0 (If there is a payment, tempcontadj
will always be $0) |
$25-$15=$10 |
$0 |
|
CPT3 |
86315 |
$10 |
$5 |
$0 |
Yes |
$10 |
$0 |
$0 |
$0 |
$0 |
|
CPT4 |
J73878 |
$15 |
N/A (Hence will replace with billed charge of $15) |
$10 |
No |
$0 |
$5 |
$0 (If there is a payment, tempcontadj
will always be $0) |
$15-$5 = $10 |
$0 |
|
Total |
|
$300 |
|
$20 |
|
$260 |
$20 |
$0 |
$20 |
$0 |
Formula
for Revenue = Billed Charge– Financial Adj
– Contractual Adj – Withheld + Refund
– TempContAdj
Since
we have Ins payment on the claims the New column (TempContAdj) is made 0 as this number is going to be
displayed under the current ContAdj column.
In
all cases the revenue is:
Revenue
= Gross – Financial Adj – Contractual Adj – Withheld + Refund – TempContAdj
= $300-$260-$20 -$0+$0-$0 = $20
The Balance showing in eCW = Billed
Charge– Ins Payment-Financial Adj – Contractual Adj
– Withheld + Refund – TempContAdj
= $300 -$20-$260-$20-$0+$0-$0 = $0
More Scenarios
Without Payment
|
Scenario |
Billed Charge |
Allowed |
Ins Payment |
Writeoff |
Cont Adj |
Temp Cont Adj |
Revenue |
Balance |
|
Formula |
|
|
|
|
|
Line item (Billed – Allowed) |
Billed-Adj |
|
|
Regular Claims |
$250 |
$150 |
0 |
0 |
0 |
$100 (250-150) |
$150 (250-100) |
$150 |
|
Partial Cap |
$300 ($250+$50) |
$30 (disregard allowed for capitated
CPT) |
0 |
$250 |
0 |
$20 (50 – 30) (disregard the capitated line item
numbers for this calculation) |
$30 (300-250-20) |
$30 |
|
Complete Cap |
$250 |
(disregard allowed for capitated CPT) |
0 |
$250 |
0 |
0 (disregard this column) |
0 (250-250) |
0 |
|
Rate Code |
$250 |
(disregard allowed for Rate Code Ins Claims) |
0 |
$66.20 |
0 |
0 (disregard this for Rate Code Ins Claims) |
183.80 (250-66.20) |
183.80 |
|
Regular Claims (unknown allowed amount) |
$250 |
Not entered (unknown) |
0 |
0 |
0 |
0 (if Allowed is not entered or zero, it is same as billed)
(250-250) |
250 |
250 |
|
|
|
|
|
|
|
|
|
|
With Payment
|
Scenario |
Billed Charge |
Allowed |
Ins Payment |
Writeoff |
Cont Adj |
Temp Cont Adj |
Revenue |
Balance |
|
Formula |
|
|
|
|
|
Line item (Billed – Allowed) |
Billed-Adj |
|
|
Regular Claims |
$250 |
$150 |
150 |
0 |
100 |
0 (disregard this if there is any ins payment) |
$150 (250-100) |
$0 |
|
Partial Cap |
$300 ($250+$50) |
$30 (disregard allowed for capitated
CPT) |
$30 |
$250 |
$20 |
0 (disregard this if there is any ins payment) |
$30 (300-250-20) |
$0 |
|
Complete Cap |
$250 |
(disregard allowed for capitated CPT) |
0 (no ins payment is expected for this claim) |
$250 |
0 |
0 (disregard this column) |
0 (250-250) |
0 |
|
Rate Code |
$250 |
(disregard allowed for Rate Code Ins Claims) |
183.80 |
$66.20 |
0 |
0 (disregard this for Rate Code Ins Claims) |
183.80 (250-66.20) |
0 |
|
Regular Claims (unknown allowed amount) |
$250 |
Not entered (unknown) |
200 |
0 |
50 |
0 (if Allowed is not entered or zero, it is same as billed)
(250-250) |
200 (250 – 50) |
0 |
|
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