Patient Member Responsibility - PMR

Estimating patient member responsibility (PMR) can be a huge component of your practice. Knowing what your patient owes at checkout can help with your collections as they can be done at time of service vs. sending patient statements.

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ChiroSpring has advanced PMR logic built in to assist you with this process. Below we will show you how to set up PMR as well as use it on a daily basis.

First you will need to set up procedure allowances (also known as allowed amounts). These are the amounts that the insurance carrier (third party payer) allows on a given charge. To setup your procedure allowances go to billing/settings/third party payers.

Once you are there, select a third party payer. Next, In the top right, click the 'Configure' button (see below). This will open up the Procedure Allowances dialog.

In the "Configure Procedure Allowances" dialog you will see all of your services. For any given service, select, first, if it is covered (check box). If it is not covered by that third party payer, leave the checkbox blank. This check box is used when estimating PMR. If a service is not covered then the estimate belongs to the patient (not the insurance).

Next, for any given charge that you marked as "Covered" you may enter the allowed amount. This can be done for up to 6 units. Below you can see for our 98941 with a default price of $40.00 that we entered $30.00 for 1 unit.

You do not need to populate all six units. The more you populate, the more accurate PMR estimation will be, of course. In addition, some services could never be billed as two units as well. If you do not populate any allowed amount, not to worry. The software will use the charge amount when calculating PMR instead of the allowed amount.

*Make sure to "Apply and save payer"

You may have also noticed a modifier section on the procedure allowances dialog. This lets you add modifiers to any service. This way when these services are added at the Fee Slip they will automatically be added! This is not only a huge time-saver, but also reduces errors as modifiers will no longer be forgotten.

*Make sure to "Apply and save payer"

Now that you have setup your procedure allowances (allowed amounts), it's time to setup insurance verification on a patient. To do this, go to the patient's dashboard/insured information.

As insurance benefits may have different coverage based on the category (e.g. chiropractic, therapy, etc.), we have defined three categories to enhance PMR calculation.

General Benefits: The 'General Benefits' category will calculate PMR on any service that is not chiropractic or therapy.

Chiropractic-Specific Benefits: For any service that falls under chiropractic, PMR will use the copay, coinsurance and deductible under this category. This section makes your PMR calculation more accurate for chiropractic codes.

Therapy-Specific Benefits: For any service that falls under therapy, PMR will use the copay, coinsurance and deductible under this category. This section makes your PMR calculation more accurate for therapy codes.

Example:

Bruce Willis receives care at Spinal Care Chiropractic and pays $70.

99203: E/M Code - Copay applied $30

98941: Chiropractic Services - Copay applied $40

97110: Physical Therapy Services - covered in copay amount

Next you will want to determine if your practice (at the practice level) wants to calculate PMR using copay, coinsurance and deductible. Some practices, as an example, may not want to collect coinsurance. In that example, you would want to uncheck (exclude) coinsurance. To access these settings go to settings/customization settings. Then select PMR preferences.

Set your PMR preferences.

We already defined our PMR calculations are incredibly accurate as we segment chiropractic, therapy and general (into three groups). For practices that do not want multiple groups you may remove groups by toggling them off. See below.

Here you can remove chiropractic specific benefits and therapy specific benefits.

For patients that may want PMR NOT to estimate based on copay or coinsurance or even deductible, you can exclude those options as well at the PER PATIENT level. To do this go to the patient. At the bottom select 'Patient Preferences'.

Then enable or disable any of the three options (see below).

Now that you have setup your procedure allowances as well as individual patient insurance, it's time to checkout your patient and see how PMR actually works. To do this, click the checkout icon from the front desk. This will open our cash register.

Here you can see all of the patient's outstanding claims and products. If you only want the patient to pay for today's visit, simply select that visit using the checkboxes.

The cash register automatically calculates the payment based on which claims/products you select. The payment amount is displayed in green (and cannot be edited). If you wish to change the payment amount change this using the 'Payment Amt.' field on the actual claim or product.

You can see the PMR for the selected claims at the bottom of the cash register.

The Cash Register also lets you accomplish the following:

• Create an appointment
• See and edit next appointment
• Request a 5-star patient review
• Print payment receipt
• Use unapplied money for products or services

Claim history clearly defines a breakdown of PMR showing insurance owes, patient owes as well as a breakdown of copay, coinsurance and deductible.

Fee schedules are not part of PMR, but do allow you to provide a discount on any service for non-insurance claims. To create a fee schedule go to billing/settings/service list & fees.

Click the + icon next to "Fee Schedules to create a new fee schedule. Once created you may edit the prices for any service.

You can set a default fee schedule for your patient on their Treatment Dashboard. This auto-populates this fee schedule for any non-insurance services added at Fee Slip. You can also change the fee schedule for non-insurance services at the fee slip at anytime.