How to View and Manually Adjust the Insurance and Patient Share Estimation

From the patient's ledger, you can review and track what is contributing to the Insurance Share and Patient Share balances.

Sensei Cloud gives you the ability to view the open claims that are driving these balances and make any needed changes to the estimation. You can manually adjust the expected insurance contribution (payment and/or write-offs) on a claim-by-claim basis, to offset any issues with missing or inaccurate estimation data.

The Ins Share value is based on the sum of associated insurance debits and credits per each open claim (Dental or Medical) or each active contract (Ortho). This includes the sum of any insurance write-offs, and the value automatically adjusts as claims are opened or closed. 

The ledger balances are calculated as follows:

• Insurance Share: Sum of the Est Ins (estimated insurance) and Ins W/O amounts from all open service claims (from the primary insurance) minus the sum of all posted insurance payments (made against the claim) and contracted insurance write-offs made against the claim. 
  Note:
  -If Ortho features are activated, any Ortho Contract amounts are included.
  -The estimate only applies to the primary insurance based on the claim chain when services are rendered/claimed (not the primary insurance that is defined in the patient record).
  
• Patient Share: Overall balance (Total Due) minus the Ins Share.
• Total Due: Sum of the Patient Share and Ins Share.

When a claim is closed, all of the underlying transactions (insurance debits and credits) associated with the claim are no longer included in the Ins Share calculation; any residual balance not covered by insurance is reallocated to the Pt Share value. 

Ledger Alerts

Sensei Cloud detects any conditions that are adversely impacting the balance calculation, and an alert icon is displayed in the Ins Share or Patient Share bucket in the ledger to warn the user.

Hold your cursor over the alert icon to view the details. 

The following are examples of conditions that may prompt an alert in the Ins Share bucket:

• There are claims that are several months old that are still open and may need to be followed up on.
• There are open claims that already have posted insurance payments, but they have been re-opened.
• There are open claims for which there is no estimated insurance coverage.

An alert may appear in the Patient Share bucket when:

• There are closed claims that have expected insurance coverage (e.g., payment or write-off), but there have been no insurance payments or write-offs posted for the claim.

Insurance Share Calculation for Patients with Orthodontic Contracts

Orthodontic and Continuation of Treatment claims are linked to their underlying contract to make it easier and more accurate to track particular insurance-based payments against a contract's insurance balance.

For patients with orthodontic contracts, the patient ledger includes Contract Balance and Current Balance buckets in addition to Total Balance, Patient Share, and Ins Share.

• Contract Balance: Sum of any outstanding orthodontic work from a contract that has not yet been charged to a patient's ledger.
• Current Balance: Sum of procedures that are currently charged to the patient's ledger.
• Total Balance: Sum of the Contract Balance and Current Balance.
• Ins Share: Sum of any posted (periodic) insurance charges, posted insurance down payments (charges), and any insurance adjustments (e.g., pre-payment) minus the sum of any insurance payments (made against Ortho or COT claims) and any contracted insurance write-offs made against Ortho or COT claims.
  
• Patient Share: Current Balance minus the Ins Share.

Users cannot adjust the Ins Share value being contributed by active Ortho contracts. However, the contract's current contribution to the Ins Share calculated balance is shown, so you can see how much of the Ins Share balance is being increased by any open ortho contracts.

To adjust the insurance coverage on a contract, select Patient > Financials > Contracts > Edit Contract. See How to Manage Insurance Changes to an Ortho Contract for more information.

Note: If there is an active orthodontic contract, a message is also displayed at the top of the Manage or Adjust Open Claims window.

When an Ortho contract is closed, all of the underlying transactions (insurance debits and credits) associated with the contract or its claims are no longer included in the Ins Share calculation, and any residual balance is reallocated to the Pt Share. 

Viewing and Manually Updating the Estimation

If your office believes the estimation is inaccurate, users with the proper permissions can view the open claims that are driving the Insurance Share calculated balance; and:

• Select the claim to review the estimation details
• Update the Est Ins (estimated insurance) or Ins W/O (insurance write-offs) and, by extension, the Pt Due values associated with the claim

Manual adjustments will be reflected in the calculated Ins Share and Patient Share balances in the Patient Ledger, allowing users to more accurately bill patients for their expected responsible amount.

Enabling Permissions

Administrators automatically have all of the necessary permissions, but users not in the Administrators group must be granted certain user permissions to perform these actions. Non-Administrators need the following settings enabled within their User Permissions (Administration > Permissions > User Permissions): 

• Claims Management > Insurance Claims Management
  This setting gives users access to the Pencil icon in the banner of the Patient Ledger, so that they can review and manage claims associated with the calculated balance.
• Financial > Claims Estimation Adjustments 
  This setting allows the user to manually adjust the estimations.

See How to Assign Group and User Permissions for more information.

Manage or Adjust Open Claims

For open (primary) service claims, you have the ability to adjust the claim-level estimation data generated at the time of claim generation, and subsequently update the Insurance Share balance.

To view the open claims associated with the insurance share, click on the Pencil icon.

The Manage or Adjust Open Claims window is displayed, and it shows a list of open (primary) service claims that are contributing to the Insurance Share balance, including data on how they are contributing.

From this window, you can use the icons under the Actions column of a claim to:

• Review the open claim record
• Adjust claim insurance coverage estimates
• Mark the claim as closed
• Post insurance payments for the claim
• Cancel the claim

To manually adjust the coverage estimates:

1. From the Manage or Adjust Open Claims window, select the Wrench icon under the Actions column of the applicable claim. The Adjust Claim Estimation window is displayed.
2. Adjust the Est Ins or Ins W/O (and, by extension, the Pt Due) values associated with the claim.
   
   Note: As you adjust the values, the Impact on the Ins Share Balance calculation at the bottom of the Adjust Claim Estimation window is also adjusted. Click Reset to return the values to their original amount.
   
3. Click Adjust. The associated claim and ledger amounts are updated.
   Note: A Wrench icon is displayed next to the claim # to indicate that the claim estimation values have been manually adjusted.
4. Click Close.

Medical Claims

Estimation is not currently supported for medical claims, but you can still manually adjust the Ins Share details of an open medical claim to calculate the Patient Share. For example, oral surgeons who are conducting pre-estimations and know what amount is going to be paid and written off for a medical claim can update the expected coverage and bill the patient for the portion they actually owe.

When the services have been posted and billed to medical insurance and a claim has been generated and released to the clearinghouse, manual adjustments can be made (e.g., using information from a pre-authorization response). 

Note: By default, the entire portion will be included in the Pt Share amount:

Manually adjust the insurance share amounts (Est Ins, Ins W/O, or both) and the Pt Share balance will recalculate accordingly.

When the Patient Share is adjusted, you can now generate a statement based on the Patient Due amount accurately.

Restoring Closed Claims

You can restore certain closed claims to open status from the ledger, if they are seen as an exception (e.g., a claim is closed with an expected insurance share or W/O, but no such transactions were posted for the claim).

To re-open a claim from the patient ledger:

1. Select the Pencil icon under the Patient Share bucket. The Review Unsettled/Unpaid Claims window is displayed.
2. Click the icon to re-open the claim. The amount for the open claim is returned to the patient's Ins Share calculation. 

You can also navigate to the patient's Claims Management list (Patient > Insurance > Claims Management) to manage, review, and re-open claims.