Payors

The Payor File stores details about the payors on the system. Payors are added and edited in the Payor File.
The Payor File window is accessed by clicking on the “Payors” option in the File menu.

What is a Payor?

A payor is a scheme that will fully or partially subsidise patient treatment.

When would I use a Payor?

A payor would be used when the patient charge due under the scheme differs to the practice’s Private fee structure.

What are some examples of typical payors a practice might set up?

  • Insurance payors such as HIC.

  • Discount Schemes – such as arrangements with corporates to treat their staff for a reduced fee.

  • Public Health payors that subsidise patients on low incomes.

(NZ only) Processing Payor Payments

See Processing Payor Payments for procedures with Non-MoH payors such as ACC, WINZ, BAYCORP, and for Ministry of Health payors, such as OHSA, SBD, and OHSA Exceptional Circumstances.

 

Adding a New Payor

  1. File > Payors:

  2. The Payor File window opens:

  3. Click the +1 button to open the Add Payor window:

  4. Complete the fields in the Add Payor window:

 

Code

Enter a unique code for the new payor. This should be consistent with payors already entered and is usually an abbreviation or acronym (e.g. ‘HIC’ for Health Insurance Commission).

Name

Enter the payor’s full name.

Address

Enter the payor’s billing address. This is the address that will appear on claims.



Payor Type

Select the Payor Type code from the drop-down list. This will determine payor functionality - see Set Payor Fees Calculation Method for further information.

Use Fees of

If this payor uses the same fees as another existing payor ( i.e. a different payor but the same fee schedule), click on the button to select that schedule.

For other fee plans, see Set Payor Fees Calculation Method.

Inactive (checkbox)

The ‘Inactive’ checkbox is used to disable a selected payor, either temporarily while setting up the payor, or at a later time.
Inactive payors cannot be selected in the Patient Details or chart window.

Course of treatment Colour

Use the Course of Treatment Colour option to assign a unique colour to the headers of Treatment Plans for this payor in the ‘Chart’ tab. This also helps identify the payor within the system. Payor colours are only used if the Patient File is configured to display treatment plan colours this way.

 

Select Optional Services

Click this button to select optional services to be charted as part of a course of treatment by the current payor. If the courses selected are missing when the course of treatment is charged, the user will be prompted to either add or ignore them. In addition, you can set up optional services to be automatically charted when a course of treatment is created for that payor, in a similar way to Quickplans.

 



Treatment Plan Colour for a Payor

The treatment plan colour allows easy identification of treatment items in EXACT by assigning the specified colour to the headers of any treatment plans for patients with this payor. It also helps to identify the payor within the EXACTsystem.

Note that this only applies if the Patient File has been configured to display treatment plan colours in this way.

  1. In either the ‘Payor File’ or ‘Add Payor’ window, click on the button.

  2. You can either choose a standard colour from the colour palette, or create a new custom colour using the red, green and/or blue sliders to create the colour of your choice. 

  3. If you have created a custom colour, and wish to use it again, save it by clicking the button.

  4. Save the changes by clicking the (‘Add Payor’ window) or the button (‘Payor File’ tab).

 

Set Payor Fees Calculation Methos

 

 

These 'radio buttons' control how patient and payor fees are apportioned for services.

Fee Schedule Methods

Description of Use

Payor sets both the service fees and the payor’s portion

Each service is manually set to indicate the patient and payor charges to be used.

Payor sets just the payor’s portion

For each service the amount the payor (scheme) will cover is entered. The patient fee will be calculated as the normal private fee less the amount covered by the payor.

Payor sets the payor’s portion and the patient discount

Allows the patient to be charged the normal private fee less a percentage discount. If the payor amount in the Payor Fee Schedule is not set to zero, this will be deducted from the private fee before the discount is calculated, and the final patient fee determined.

If you need to use more than one discount rate, use the Combination Payor below, which allows the discount % to be set for individual items.

Combination

Allows the use of all the above Fee Schedule types. In the fee schedule window each service is manually set to indicate which method is to be used.

 

This box determines whether the ‘cost’ noted for a given service item is added on to the fee for the patient to pay (ticked) or assumed to be built into the fee (unticked).

 

Enter the payor’s phone number for following up on claims.

 

Enter the payor’s fax number for faxing any materials in support of claims.

 

Once the new payor is active, the current balance owed by them on outstanding claims, will be displayed in this area of the payor file.

 

The default Payor Type is ‘Others’. If the payor relates to a government claiming scheme supported by EXACT there will be an option for this Scheme in the drop-down list. Selecting one of these payors will trigger other features within EXACT necessary to fully support the scheme, such as giving access to the Bands Setup window, activating buttons on the Payor File window, and prompting for claiming information at the end of treatment.

 

Click this button to select optional services to be charted as part of a course of treatment by the current payor. If the courses selected are missing when the course of treatment is charged, the user will be prompted to either add or ignore them. In addition, you can set up optional services to be automatically charted when a course of treatment is created for that payor, in a similar way to Quickplans.

Click to complete the process of setting up a payor.

 

Options in the Payor File Window

Once a new Payor record has been saved, a number of buttons are available relating to that Payor in the ‘Payor File’ window:

 

The ‘Fee Schedule’ button opens a window in which to import and edit fees for services, for the selected Payor.

 

 

Clicking this button will open the “Increase Payor Fees” window, to enable you to adjust the payor fees, as at a specified date:

 

The ‘Claim’ button is used to bundle claims to be submitted to the Payor, or for printing claim reports.

 

The 'Bands Setup' button is only active if the current payor is set up as a capitation payor.

 

Payor Transactions

In the Payor File window, click the transactions button $ to display the “View Payor Transactions” window, showing the transactions for the current payor.

 

Columns:

Date

The transaction date.

 

The type of transaction. This will be represented by one of several different icons; click the button for an explanation of what each icon means.

 

“TC Response” status. This will be represented by one of several different icons; click the button for an explanation of what each icon means.

 

Accepted

Num

The transaction number.

Provider

The name of the provider who carried out the treatment.

Details

Transactions details (the patient’s name).

Amount

The transaction amount.

Amt Open

Displays amounts that have not yet been allocated.

 

“Change Column Settings” button: enables the columns to be reordered, the widths changed, etc.

Double-click a transaction line to view the details of the transactions that make up that line.

Buttons / Other Fields:

 

Click this button to view the explanation of each icon.

Sort by Date

This can be used when there is a long list of transactions. Entering a date in this field will move the cursor to the first transaction line for that date.

Provider

If this field is blank, transactions for all providers will be listed. Alternatively, enter (or select from the list, or using the arrow keys) a single provider code, and only transactions for that provider will be displayed.

 

Click this button to resubmit a COT.

 

Closes the Payor Transaction window.

 

This button is used to transfer a transaction to another patient, such as another member of the family.

 

This allows you to make adjustments.

 

Used to allocate transactions against a payment, such as when a patient sends in a cheque and it has to be allocated against more than one COT.

 

Shows the details for the transaction.

Show open
Treatment

Tick this box to include treatment that has not yet been TC'd, or remove the tick if only completed COTs are to be shown.

Show Resubmissions

Tick this box to show resubmitted transactions, or clear it to exclude resubmissions.

 

Displays appropriate details (allocations, claim info, etc.) for the current line.

 

Prints an invoice or summary for the current line.

 

Deletes the current line.