Coding, Claims, and Clearinghouse
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      Patient Responsibility [PR] Calculation

      How AngelTrack calculates the patient responsibility [PR] amount using EOBs returned by carriers

      AngelTrack calculates the patient responsibility [PR] amount separately from the gross balance; however, the calculation is at times ambiguous, and so you must understand how it works and how it can fail.

      PR Amounts Change the Balance Due

      When the Payor is set to "Patient," PR amounts can change the balance due if a secondary carrier has disallowed any additional amounts or has forbidden patient copays. These additional disallowances are sometimes called "Not Allowed Amounts," or NAA.

      To learn more, read how AngelTrack calculates the balance due.

      Ambiguous PR Amounts in EOBs

      AngelTrack calculates the PR by analyzing the EOBs returned by the carriers. However, this calculation is not always certain.

      The main difficulty of PR calculation arises from an ambiguity in how insurance carriers issue their EOBs, be they electronic or on paper, as illustrated by these examples:

      • If a first EOB says the PR is $50, and then a second EOB (without an intervening re-claim) from the same carrier says the PR is $10, it is not clear whether the new PR is $10 or is $60 ($50 + $10).
      • Denials will sometimes say the PR is zero, even though the patient is actually responsible for the full balance since the patient signed the promise-to-pay form.
      • If a first EOB says the PR is $50, and then a second EOB from the same carrier reverses and says the PR is now -$50 or zero, it is not clear whether the new PR is supposed to be zero or else be the full balance.
      • When a carrier writes a check directly to the patient, the EOB sometimes reports that amount as an ambiguous OA*100 adjustment rather than a proper PR*100 amount that is to be recaptured from the patient*.

      In other words, EOBs have an inherent and crucial ambiguity: When they say the PR is zero, it could actually be either zero or the entire balance. When a carrier denies or reverses and says the PR is zero, they are assuming that no "Promise to Pay" signature is on file... even though such an assumption is typically always wrong.

      AngelTrack must struggle to decide how to interpret a PR of zero, deciding whether it means "zero due" versus "entire balance."

      Ambiguities Resulting from Errors in Payment Event Records

      AngelTrack separately calculates the PR set by each of the carriers in play -- primary, secondary, and tertiary -- by analyzing the approval/denial payment events on file from them. The results of these calculations are shown on the "Billing" tab of Dispatch Edit, next to the balance due. The calculation works like this:

      1. Find the payment event representing the most recent claim against, or denial/reversal from, the carrier.
      2. Iterate all approval and reversal payment events on file after that event, and add up all associated PR adjustments (CAS03, not CLP05). CLP05 is ignored because it is often incorrectly set to zero when negative PR adjustments are present.
      3. Any approval or reversal payment event is ignored if it contains CO*18 or OA*18 codes indicating that it is dupe-claim advice.
      4. Any approval or reversal payment event is assumed to have a PR of zero if it contains the MA125 remark code, indicating a statutory prohibition of patient copays.

      The calculations depend on the accuracy of the payment event records, and so the numbers will be wrong if payment events are misfiled as primary/secondary/other. This can occur when secondary carriers erroneously claim (in CLP02) to be the primary adjudicator, and billers do not always notice and correct this during EDI import. When that secondary carrier specifies a PR but the associated payment is misfiled as being from the primary, then AngelTrack will incorrectly add it to the primary's accumulated PR as though it is a reconsideration.

      Automatic Defenses Against PR Errors

      To defend against the possibility of overbilling a patient due to an incorrect PR, AngelTrack does the following:

      • Any PR amount that exceeds either the price quote (counting discounts and fees) or the price allowed (not counting discounts and fees) is ignored.
      • If the primary carrier does not have a PR determination on file, then any PR set by a secondary or other carrier is ignored.
      • If a tertiary carrier sets a PR higher than that set by the secondary, it is ignored.

      If all PRs on file are thereby ignored, then the patient will be invoiced only for the normal balance. In most cases, the normal balance is the same as whatever PR the carriers intended to set, and so nobody will be under or over-billed.

      PR higher than balance

      There are at least three situations where the PR can ask for the patient to be billed for more money than is actually due per the allowed price that the primary carrier adjudicated:

      • While inputting a paper EOB from a secondary who paid off the full PR, the biller left the PR field blank (i.e. "[Entire balance]") rather than zero. That will cause the primary carrier's PR determination to "win," even though the secondary carrier paid it all and thereby asked to set the PR to zero.
      • Chaotic payment event records have caused a carrier's PR assertions to be double-counted or uncounted.
      • An incorrectly low amount in the Price Allowed field might undershoot the adjudicated PR.

      In these cases, AngelTrack will invoice the patient for whichever is lesser of the PR or the balance. If due to a PR error, this can result in a patient being asked to pay less than what the carrier(s) assert is their responsibility, which is a problem.

      PR lower than balance

      There are at least four situations where the PR can ask for the patient to be billed for less money than is actually due per the allowed price that the primary carrier adjudicated:

      • The secondary carrier adjudicates a "Not Allowed Amount" [NAA] in addition to what the primary carrier disallowed. For example, for a claim of $1000, the primary may disallow $1800, allow $200, pay $150, and leave $50 as the PR. The claim for $50 then goes to the secondary, who disallows an additional $5, pays $35, and leaves $10 as the final PR. In this situation, the balance (versus the price allowed by the primary) will be $15, but the PR will be $10. AngelTrack will invoice the patient for the $10, and once that's paid, will write off the $5 NAA.
      • A Medicaid carrier can deny all patient copays, either by issuing remark code MA125 or by simply omitting any PR adjustments, in which case the typical $50 copay will remain as the balance, but nothing will be owed by the patient, and so AngelTrack will suggest writing off the $50.
      • Chaotic payment event records might mislead AngelTrack into deciding that the last carrier's PR determination is zero. You can review AngelTrack's PR determinations using the "Billing" and "Pmt Events" tabs of Dispatch Edit.
      • An incorrectly high amount in the Price Allowed field might exceed the PR, creating the illusion of an NAA.

      Because AngelTrack will invoice the patient for whichever is lesser of the PR or the balance, these situations can cause the patient to be underbilled but never overbilled.

      Manual Correction of PR Errors

      If you see a PR that is unexpectedly low, high, or missing, do the following:

      1. Review the payment event records to see if any are misfiled as primary, secondary, or tertiary. The "Pmt Events" tab under Dispatch Edit lists them all, along with their PR determinations if any. Remember that a null (missing) PR determination is not the same as a zero PR determination.
      2. If a carrier's PR is still too high, see if it has been set twice after the latest claim event against that carrier, and if so, add the missing re-claim event between the two approvals, or zero out the PR in the later payment event record(s).
      3. Make sure any full-reversals are filed as denials so as to clear the zero PR created by the reversal and thereby revert the PR to be "[Not set]" i.e. the full balance.
      4. If any payment events were hand-typed from paper EOBs, double-check the tables of adjustments to see if any PR/COINS rows contain typographical errors or were accidentally omitted.

      *The Problem With OA*100 Payments from Carrier to Patient

      When an insurance carrier writes a check directly to the patient, with the intention that EMS is to then bill the patient for it, they are supposed to report the check amount as PR*100 adjustments. That way, AngelTrack knows to add the carrier's check amount to the patient's invoice.

      The problem is that carriers will sometimes report the check as an "Other Adjustment" aka OA*100, rather than PR*100. AngelTrack cannot automatically add these OA*100 amounts to the patient's invoice because we have observed cases where carriers erroneously report an OA*100 amount which they did not actually pay to the patient.

      If you believe that an OA*100 amount is true and correct, and wish to invoice the patient for it, then you must manually add the amount to the "Patient responsibility" value set in the respective payment event.