Understanding Scheduled and Actual Production Calculations

The document provides information regarding the calculations for scheduled and actual production (gross and net).

Calculations

Gross scheduled production

Gross scheduled production is the sum of the Scheduled Charges for the scheduled procedures.

If the scheduled procedure has a Planned status, the Provider is the rendering provider (according to the insurance defaults); otherwise, if the scheduled procedure has an Other status, the Provider is the scheduled provider (the provider assigned to the appointment).

If the Provider has a fee schedule, the Scheduled Charge comes from that fee schedule; otherwise, the Scheduled Charge comes from the preferred fee schedule of the location where the procedure is scheduled.

Gross actual production

Gross actual production is the sum of the Procedure Charges for the completed procedures. Optionally, the gross actual production can include the sum of any charge adjustments (depending on the schedule's view options).

The Procedure Charge is the charged amount for a posted procedure (with a Complete status) on a patient's ledger.

Net scheduled production

Net scheduled production is the sum of the Scheduled Charges for the scheduled procedures, minus any discounts or insurance adjustments that are applied to those procedures. Remaining benefits and deductibles are excluded from the calculation.

The Provider and Procedure Charge are determined according to the following criteria:

  • For a scheduled procedure with a Planned status:

    • If the patient has insurance coverage, and if the procedure is flagged as Bill to insurance, the Provider is the billing provider (according to the insurance defaults).

    • The Procedure Charge is the charged amount for a treatment-planned procedure in a patient's clinical progress notes.

  • For a scheduled procedure with an Other status:

    • The Provider is the scheduled provider (the provider assigned to the appointment).

    • If the Provider has a fee schedule, the Procedure Charge comes from that fee schedule; otherwise, the Procedure Charge comes from the preferred fee schedule of the location where the procedure is scheduled.

The Scheduled Charge is determined according to the following criteria:

  • If the patient has primary insurance coverage:

    • If the procedure is flagged as Bill to insurance:

      • If the patient has secondary insurance coverage:

        1. Get the Primary Write-off:

          • If the primary insurance plan has a contracted fee schedule:

            • If the Provider is contracted with the carrier:

              • Without a Primary Insurance Estimate Override:

                • For a coverage table based on patient copayments ($):

                  • Without a Primary Insurance Estimate Override, take the greater of the Primary Max Allowable Amount (from the contracted fee schedule) and the Primary Patient Copay, subtract that from the Procedure Charge, and then set the Primary Write-off equal to that difference unless that difference is less than zero, in which case, set the Primary Write-off equal to zero.

                  • With a Primary Insurance Estimate Override, take the greater of the Primary Max Allowable Amount (from the contracted fee schedule), Primary Patient Copay, and Primary Insurance Estimate Override; subtract that greater amount from the Procedure Charge; and then set the Primary Write-off equal to that difference.

                • For a coverage table based on insurance coverage percentages (%), subtract the Primary Max Allowable Amount (from the contracted fee schedule) from the Procedure Charge, and then set the Primary Write-off equal to that difference unless that difference is less than zero, in which case, set the Primary Write-off equal to zero.

            • If the billing provider is not contracted with the carrier, set the Primary Write-off equal to zero.

          • If the primary insurance plan does not have a contracted fee schedule, there is not a Primary Write-off, so set the Primary Write-off equal to zero.

        2. Get the Secondary Write-off:

          • If the secondary insurance plan has a contracted fee schedule:

            • If the Provider is contracted with the carrier:

              • For a coverage table based on patient copayments ($):

                • Without a Secondary Insurance Estimate Override, take the greater of the Secondary Max Allowable Amount (from the contracted fee schedule) and Secondary Patient Copay, subtract that from the Procedure Charge, and then set the Secondary Write-off equal to that difference unless that difference is less than zero, in which case, set the Secondary Write-off equal to zero.

                • With a Secondary Insurance Estimate Override, take the greater of the Secondary Max Allowable Amount (from the contracted fee schedule), Secondary Patient Copay, and Secondary Insurance Estimate Override; subtract that greater amount from the Procedure Charge; and then set the Secondary Write-off equal to that difference.

              • For a coverage table based on insurance coverage percentages (%), subtract the Secondary Max Allowable Amount (from the contracted fee schedule) from the Procedure Charge, and then set the Secondary Write-off equal to that difference unless that difference is less than zero, in which case, set the Secondary Write-off equal to zero.

            • If the billing provider is not contracted with the carrier, set the Secondary Write-off equal to zero.

          • If the secondary insurance plan does not have a contracted fee schedule, there is not a Secondary Write-off, so set the Secondary Write-off equal to zero.

        3. Get the Max Write-off:

          The Max Write-off is the greater of the Primary Write-off and the Secondary Write-off.

        4. Get the Scheduled Charge:

          • If the Max Write-off is zero (0), the Scheduled Charge is the Procedure Charge.

          • If the Max Write-off is greater than zero (0):

            1. Check if a Primary Insurance Estimate Override has been entered for the procedure:

              • With a Primary Insurance Estimate Override, the Primary Insurance Estimate is the override amount.

              • Without a Primary Insurance Estimate Override, check for an insurance coverage exception:

                • For a coverage table based on patient copayments ($):

                  • If there is an exception, subtract the Primary Patient Copay Exception from the lesser of the Procedure Charge and Primary Max Allowable Amount (from the contracted fee schedule), and then set the Primary Insurance Estimate equal to that difference; however, if that difference is less than zero (0), set the Primary Insurance Estimate equal to zero (0).

                  • If there is not an exception, subtract the Primary Patient Copay from the lesser of the Procedure Charge and Primary Max Allowable Amount (from the contracted fee schedule), and then set the Primary Insurance Estimate equal to that difference; however, if that difference is less than zero (0), set the Primary Insurance Estimate equal to zero (0).

                • For a coverage table based on insurance coverage percentages (%):

                  • If there is an exception, the Primary Insurance Estimate is the product of the Primary Insurance Coverge Exception and the lesser of the Procedure Charge and Primary Max Allowable Amount (from the contracted fee schedule); however, if that product is less than zero (0), the Primary Insurance Estimate is zero (0); and if an exception exists, but there is not a coverage range for it, the Primary Insurance Estimate is zero (0).

                  • If there is not an exception, the Primary Insurance Estimate is the product of the Primary Insurance Coverage and the lesser of the Procedure Charge and Primary Max Allowable Amount (from the contracted fee schedule); however, if that product is less than zero (0), the Primary Insurance Estimate is zero (0).

            2. Check if a Secondary Insurance Estimate Override has been entered for the procedure:

              • With a Secondary Insurance Estimate Override, the Secondary Insurance Estimate is the override amount.

              • Without a Secondary Insurance Estimate Override, check for the secondary insurance plan's coordination of benefits (COB):

                • Traditional:

                  • For a coverage table based on patient copayments ($):

                    • If there is an exception, subtract the Secondary Patient Copay Exception from the lesser of the Procedure Charge and Secondary Max Allowable Amount (from the contracted fee schedule), and then set the Secondary Insurance Estimate equal to that difference; however, if that difference is less than zero (0), set the Secondary Insurance Estimate equal to zero (0).

                    • If there is not an exception, subtract the Secondary Patient Copay from the lesser of the Procedure Charge and Secondary Max Allowable Amount (from the contracted fee schedule), and then set the Secondary Insurance Estimate equal to that difference; however, if that difference is less than zero (0), set the Secondary Insurance Estimate equal to zero (0).

                  • For a coverage table based on insurance coverage percentages (%):

                    • If there is an exception, the Secondary Insurance Estimate is the product of the Secondary Insurance Coverge Exception and the lesser of the Procedure Charge and Secondary Max Allowable Amount (from the contracted fee schedule); however, if that product is less than zero (0), the Secondary Insurance Estimate is zero (0); and if an exception exists, but there is not a coverage range for it, the Secondary Insurance Estimate is zero (0).

                    • If there is not an exception, the Secondary Insurance Estimate is the product of the Secondary Insurance Coverage and the lesser of the Procedure Charge and Secondary Max Allowable Amount (from the contracted fee schedule); however, if that product is less than zero (0), the Secondary Insurance Estimate is zero (0).

                • Maintenance of Benefits:

                  • For a coverage table based on patient copayments ($):

                    • If there is an exception, take the lesser of the Procedure Charge and Secondary Max Allowable Amount (from the contracted fee schedule), subtract the Primary Insurance Estimate from that lesser amount, subtract the Secondary Patient Copay Exception from that difference, and then set the Secondary Insurance Estimate equal to the resulting difference; however, if the difference is less than zero (0), set the Secondary Insurance Estimate equal to zero (0).

                    • If there is not an exception, take the lesser of the Procedure Charge and Secondary Max Allowable Amount (from the contracted fee schedule), subtract the Primary Insurance Estimate from that lesser amount, subtract the Secondary Patient Copay from that difference, and then set the Secondary Insurance Estimate equal to the resulting difference; however, if the difference is less than zero (0), set the Secondary Insurance Estimate equal to zero (0).

                  • For a coverage table based on insurance coverage percentages (%):

                    • If there is an exception, take the lesser of the Procedure Charge and Secondary Max Allowable Amount (from the contracted fee schedule), subtract the Primary Insurance Estimate from that lesser amount, multiply that difference times the Secondary Insurance Coverage Exception, and then set the Secondary Insurance Estimate equal to the resulting product; however, if that product is less than zero (0), set the Secondary Insurance Estimate equal to zero (0); and if an exception exists, but there is not a coverage range for it, set the Secondary Insurance Estimate equal to zero (0).

                    • If there is not an exception, take the lesser of the Procedure Charge and Secondary Max Allowable Amount (from the contracted fee schedule), subtract the Primary Insurance Estimate from that lesser amount, multiply that difference times the Secondary Insurance Coverage, and then set the Secondary Insurance Estimate equal to the resulting product; however, if that product is less than zero (0), set the Secondary Insurance Estimate equal to zero (0).

                • Carve Out/Non-duplication:

                  • For a coverage table based on patient copayments ($):

                    • If there is an exception, take the lesser of the Procedure Charge and Secondary Max Allowable Amount (from the contracted fee schedule), subtract the Primary Patient Copay Exception from that lesser amount, subtract the Primary Insurance Estimate from that difference, and then set the Secondary Insurance Estimate equal to the resulting difference; however, if the difference is less than zero (0), set the Secondary Insurance Estimate equal to zero (0).

                    • If there is not an exception, take the lesser of the Procedure Charge and Secondary Max Allowable Amount (from the contracted fee schedule), subtract the Primary Patient Copay from that lesser amount, subtract the Primary Insurance Estimate from that difference, and then set the Secondary Insurance Estimate equal to the resulting difference; however, if the difference is less than zero (0), set the Secondary Insurance Estimate equal to zero (0).

                  • For a coverage table based on insurance coverage percentages (%):

                    • If there is an exception, take the lesser of the Procedure Charge and Secondary Max Allowable Amount (from the contracted fee schedule), multiply that lesser amount times the Primary Insurance Coverage Exception, subtract the Primary Insurance Estimate from that product, and then set the Secondary Insurance Estimate equal to the resulting difference; however, if that difference is less than zero (0), set the Secondary Insurance Estimate equal to zero (0); and if an exception exists, but there is not a coverage range for it, set the Secondary Insurance Estimate equal to zero (0).

                    • If there is not an exception, take the lesser of the Procedure Charge and Secondary Max Allowable Amount (from the contracted fee schedule), multiply that lesser amount times the Primary Insurance Coverage Exception, subtract the Primary Insurance Estimate from that product, and then set the Secondary Insurance Estimate equal to the resulting difference; however, if that difference is less than zero (0), set the Secondary Insurance Estimate equal to zero (0).

            3. Get the Insurance Portion:

              The Insurance Portion is the sum of the Primary Insurance Estimate and the Secondary Insurance Estimate.

            4. Get the Scheduled Charge:

              • If the Insurance Portion is greater than or equal to the Procedure Charge, the Scheduled Charge is the Procedure Charge.

              • If the Insurance Portion is less than the Procedure Charge:

                • If the sum of the Insurance Portion and the Max Write-off is greater than the Procedure Charge, the Scheduled Charge is the Insurance Portion.

                • If the sum of the Insurance Portion and the Max Write-off is less than or equal to the Procedure Charge, the Scheduled Charge is the Procedure Charge minus the Max Write-off.

      • If the patient does not have secondary insurance coverage:

        • If the billing provider is contracted with the primary insurance carrier:

          • If the primary plan has a contracted fee schedule, the Scheduled Charge comes from the lesser of the contracted fee and the Procedure Charge.

          • If the primary plan does not have a contracted fee schedule, the Scheduled Charge is the Procedure Charge.

        • If the billing provider is not contracted with the primary insurance carrier, the Scheduled Charge is the Procedure Charge.

    • If the procedure is not flagged as Bill to insurance, the Scheduled Charge is the Procedure Charge.

  • If the patient does not have primary insurance coverage:

    • If the patient has a discount fee schedule:

      • If the discount fee is greater than the Procedure Charge, the Scheduled Charge is the Procedure Charge.

      • If the discount fee is equal to or less than the Procedure Charge, the Scheduled Charge comes from the discount fee schedule.

    • If the patient does not have a discount fee schedule, the Scheduled Charge is the Procedure Charge.

Net actual production

Net actual production depends on patients' insurance coverages:

  • With insurance coverage, the sum of the Procedure Charges, minus the total of any write-off adjustments and the total of any applied credit adjustments.

  • Without insurance coverage, the sum of the Procedure Charges, minus the total of any applied credit adjustments.

Optionally, the net actual production can include the total of any charge adjustments, and/or the total of any unapplied credts can be deducted from the net actual production (depending on the schedule's view options).

The Procedure Charge is the charged amount for a posted procedure (with a Complete status) on a patient's ledger.