For customers in the United States, the insurance estimation feature in Sensei Cloud provides estimates for the patient and insurance due amounts for billed work, taking into account the patient's benefits remaining and deductible remaining amounts.
The estimation is handled in groups in regard to treatment plans, appointments, posted procedures, and claims, rather than estimating items independent of one another, to provide a more accurate projected insurance coverage.
Estimation is based on the current data defined in the patient's policy record (within the Patient Record).
Note: For the estimations to calculate the patient and insurance due amounts accurately, the patient must be assigned an active insurance policy, and the insurance plan needs to have a defined allowance table. See How to Add or Update Patient Insurance and How to Add or Edit Coverage Details for an Insurance Plan for more information.
This policy information is taken into account for the given set of work, within an appointment, treatment plan, or set of procedures to be posted or claimed. Up to the point where these items are billed (e.g., a claim is generated), the system continually recalculates the estimation data based on the latest known information (e.g., the information included in the allowance table, the patient's assigned primary insurance, how much deductible / remaining benefits apply, etc.).
Estimation calculations reflect the procedure order, grouping, and current available benefits when treatment planning, posting new charges, or generating a claim:
- How to Create or Edit a Patient Treatment Plan
- How to Post Charges and Payments from the Patient Ledger
- How to Manage Secondary and Subsequent Insurance Claims
You can enable insurance estimation default settings (Administration > Practice Settings > Financial Rules > Edit Financial Rules) to automatically update a patient's remaining deductible and benefits, and to automatically reset benefits and deductibles when an active insurance plan's defined coverage period ends. See How to Enable Automatic Updates to a Patient Remaining Deductible and Benefits for more information.
Note: The estimation calculations reflect the specific procedure order and claim order.
For example, a patient may have a treatment plan that includes multiple procedure codes that are split into two groups. The deductible and benefits remaining are applied to the first procedure, and then any remaining benefits apply to the second procedure in the group, etc.
The estimation calculation accounts for the deductible or benefits remaining potentially no longer being available for the subsequent procedures (if the insurance estimate for the first procedure uses the entirety of the benefits remaining).
The deductible is included in the calculation of the estimate up until it is met, and when a patient runs out of benefits, the system knows to stop calculating an insurance payment, and instead calculates any remaining amount due as part of the patient due amount.
Estimated Patient and Insurance Due
The estimated patient and insurance due amounts are updated continuously based on the latest data. This ensures that the estimated amounts are re-estimated at the time of claim creation, accounting for any change in conditions between when the posted work was completed and when it was claimed, changes to the original estimate and what is claimed, or both.
Live, ongoing estimation calculation (e.g., for appointments or treatment plans, or even posted, but not billed work) happens until the point of billing to insurance (e.g., claim creation). Prior to billing to insurance, the patient and insurance due estimations in the following locations are calculated and re-calculated based on the latest information:
Appointment Creation Window - The Total Due (Patient Due) amounts are displayed below the procedure codes that have been added to the appointment. Click the Total Due (Pt Due) button to view additional insurance estimation details.
Schedule Day View - The Total (Patient Due) amounts are displayed when you click on an appointment tile in the schedule.
Note: If you add or remove a procedure when you complete check out for a patient and then post charges for the appointment, the Total Due (Patient Due) estimated amounts update in real time.
For example, if you remove the first procedure from the appointment, the estimated insurance for the remaining procedure updates since the deductible that was applied to the first procedure now applies to the next procedure instead.
See How to Check Out a Patient After Completing an Appointment for more information.
Treatment Plan - The Total Fee (Patient Due) amounts for the procedures included in a treatment plan are visible in the Viewing Treatment Plan window (Patient > Treatment Plans > Select a treatment plan).
The Total Fee (Patient Due) amount at the top of the window is a total fee of all groups included in the plan. If there are multiple groups within the plan, you can also see the totals for each individual group. Click on any of the Total Fee (Pt Due) buttons to view additional insurance estimation details.
Note: See How to Create or Edit a Patient Treatment Plan for more information.
Patient Share and Insurance Share
When procedures are posted and billed to insurance, they contribute to the Patient Share and Insurance Share balances, which are displayed in the patient ledger.
Note: If something is posted but not billed to insurance, then it is only contributing to the Patient Share balance (even if it had associated estimation data). The estimation only has an impact on the Insurance vs. Patient Share balance calculation once it has been claimed.
These balances are visible in the patient ledger:
Patient Ledger - The Patient Share and Insurance Share amounts are displayed at the top of the ledger. Click on individual transactions to view more information, such as the estimated insurance (+ write-off) amount.
See How to Work With the Patient Ledger for more information.
Manually Updating the Estimation from the Patient Ledger
Insurance estimation is locked in at the time of claim creation, but the calculated estimation for the claimed procedures can be manually adjusted after the fact from the patient's ledger.
See How to View and Manually Adjust the Insurance and Patient Share Estimation for more information.