Split percentage is a type of payor program that allows you to generate invoices for billable items according to the percentages set for each payor on the contract version currently in effect on the program. Split percentage works well in billing scenarios where various payors are responsible for a fixed percentage of the overall cost of a client’s care.
You can only have one contract on a program in effect at one time. However, you can delete contracts and create multiple versions with different effective dates, payors, and percentage breakdowns.
For this program type, you can set different guarantors at the program and contract levels. The guarantor at the program level is responsible for covering the full cost of billable items when there is no contract in effect. In this scenario, only one invoice will be generated with the program guarantor as the bill-to party. The guarantor at the contract level is responsible for covering the remaining cost of billable items for client in a billing period after the distribution percentages for all the payors have been applied.
Note that the distribution percentages for each payor on a contract are always applied to the total cost of billable items, not the remaining amount after the percentage covered by the first payor has been applied. (For example, if payor 1 covers 50%, payor 2 30%, and the guarantor 20%, for a visit that costs $100, payor 1 will be invoiced $50, payor 2 $30, and the guarantor $20).
You also have the option to split premiums as well as visits between multiple bill-to parties. When setting up the program for the client, you can choose whether you wish to split premiums based on distribution percentages or whether all premiums will be 100% covered by either a payor or guarantor.
Creating a split percentage payor program for a client
Payor programs are set up at the client level.
You must be in a role configured with the View payor program and Manage payor program ACLs in settings>roles and permissions to view, add, and edit payor programs for clients.
To add a new program, go to Accounting>Payor programs on the client’s profile and select +Add program.
In the Add payor program dialogue, enter the Name of the payor program and select Split percentage as the Type.
Select a client individual or funder individual funder as the Guarantor outside of coverage. This is the program level guarantor who will cover the total cost of any billable items linked to a program that do not fall within the coverage range defined on a contract.
If you select a client individual funder, you will also need to select a Billing contact.
Check the box next to Split premiums using this program if you wish to split the cost of premiums between multiple payors.
Finally, select a Billing frequency for the program. In payor invoicing, the billing periods are determined by the billing frequency. The available frequencies are 1 week, 2 weeks, 4 weeks, and Calendar month. When you have finished, click Save.
The program will open as a new screen. Select Edit to make changes to the program details.
Note that once a contract has been added to the program, you will not be able to change whether you are splitting premiums for this program. Once invoices have been generated for a program, you will only be able to edit the program name and billing frequency.
To add a contact to the program, select +Add contract.
In the Add contract dialogue, enter the Coverage start date along with the Contract number if necessary. The Coverage end date will be updated when a new version of the contract is created. Note that you cannot manually enter an end date for a contract.
In the Payors section, the guarantor that you selected at the program level will already be listed with 100% as the distribution percentage.
Click Edit if you wish to set a different guarantor at the contract level. This guarantor will cover the percentage not covered by any other payors you add to the contract.
Select Add payor to add a payor to the contract.
Select a funder of type client individual or funder individual in the Payor column. In the Distribution column, enter the percentage of the billable items that this payor will be responsible for. The distribution percentage of the guarantor will be automatically adjusted.
If you select a funder of type client individual, you will also need to select a Billing contact.
If Split premiums using this program is selected, the distribution percentage for each payor entered will apply to premiums funded by the program as well as visits.
If you did not select Split premiums using this program, an additional column will appear in the payors list called Premium(s) covered in full. For each payor you add to the list, you will be able to select the premiums from Accounting>Accounting settings>Premiums using the + multi-select button that should be 100% covered by that payor.
Note that you can delete a payor from the list, but you cannot delete the guarantor. Every contract must have a guarantor listed.
When you are finished adding the payor, select Done.
Click Add payor again to add more payors to the contract. Note that you cannot add the same funder of type funder individual more than once.
For contracts where premiums are covered in full, the number of premiums covered by each payor will be displayed in the Premium(s) covered in full column. The guarantor will be responsible for covering in full any premiums funded by the program that are not selected for coverage by one of the payors on the contract.
When you have finished with the contract, click Save.
Once a contract has been created, the Add contract button will change to Add version. To delete the contract, select Delete. To edit the contract, select Edit.
If invoices have not yet been generated for the contract (or if any generated invoices have been voided or deleted), you will be able to edit all fields on the contract.
To add a new version of the contract, select Add version.
In the Add version dialogue, you can adjust the contract number, coverage start and end dates, and payors list as needed. The guarantor set on the previous version of the contract will automatically populate in the new version but can be edited as needed.
If a coverage end date was not on the previous version of the contract, it will be set as the coverage start date of the new version minus one date.
When you have finished entering the version details, click Save.
Note that only the most recent version of the contract can be edited or deleted.