About Contracts

Healthcare providers may have differing fees for services depending on the billing situation. For example, a provider may have one set of fees for self-pay patients but a different set of pre-negotiated fees for payers such as insurance companies. All fees are determined by the fee schedule associated with a contract. You must set up one or more contracts and their corresponding fee schedules before billing for medical services.

There are two types of contracts:

Practice Standard - Used to track the usual and customary fees applicable to a provider. When entering encounters for a self-pay patient or a patient whose insurance plan is not associated with a specific contract, fees are automatically determined by the Practice Standard contract.
Insurance-Specific - Used to track a pre-negotiated fee schedule associated with a contract between a health care provider and a government payer or an insurance company. When entering encounters for a patient whose insurance plan is associated with a specific contract, fees are automatically determined by the Insurance-Specific contract.

In addition, there is a checkbox under the "General" tab of the contract that is enabled when a user selects the contract type as "Insurance-Specific." By checking this box, all procedures by default will be treated as covered by the capitated insurance plan. This means that the system will automatically adjust the balance on capitated charges to $0.00 upon approving an encounter where the primary insurance policy is governed by a capitated payer. However, you can also carve out specific procedures as fee-for-service exceptions to the capitated insurance plan by adding the procedures and charge amount to the "Fee Schedule" tab of the corresponding capitated contract (see Import Fee Schedule). You can also set up capitated accounts in the system and apply portions of a payment to a capitated account. (For more information on setting up a capitated account, see About Capitated Accounts.)