Insurance Fee Schedules, Coinsurance, and Invoicing

Insurance Fee Schedules, Coinsurance, and Invoicing

Patient Coinsurance % is calculated using CPT code's Maximum Allowed Rate instead of CPT code's Billed Amount (the price your practice has set for the CPT code) since a patient’s coinsurance should be a percentage of what is allowed rather than what is billed to insurance. Click here to know how to add coinsurance information to a patient chart.


Let’s say we’re billing out two billing codes - $50 and $60 - to an insurance payer - ABC. We know that ABC will allow $20 for our first CPT code and $30 for our second CPT code. We also know that our patient has a 20% Coinsurance.

Scenario #1 - You Have Not Entered Maximum Allowed Rates (Fee Schedules)

If you don't enter the maximum allowed rates (fee schedules) for ABC insurance company and patient's coinsurance, this is what the invoicing looks like:

Patient Balance: $0

Insurance Balance: $110 (full amount billed to insurance)

Scenario #2 - You Have Entered Maximum Allowed Rates (Fee Schedules)

Here’s what the invoicing looks like after you’ve entered Maximum Allowed Rates and Coinsurance:

Patient Balance: $10 (20% of $50 - Total Allowed Amount for two CPT codes mentioned above)

Insurance Balance: $100

What If A Patient Doesn’t Have Coinsurance?
Even if a patient doesn’t have a Coinsurance, entering Maximum Allowed Rate (Fee Schedule) for all CPT codes for each insurance payer can help make your Accounts Receivable more accurate and save you some time down the road.

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