Assign an Insurance Agent to a Client
After adding a new insurance company and insurance category in the previous tutorial, we will now link them with the clients so that the system can automatically apply insurance when creating invoices for this client. To do this, we need to have clients in the account.
Since we already have clients in our eyewear shop account, we will select one of our clients,
First, we click on ‘Clients’ in the main menu, then ‘Manage Clients,’ and select ‘Client 1’ as shown in the image.
From the client profile click on “edit“,
Below the “Account Details” field in the client’s data control panel, you will find two options:
- Insurance Company: Select from the available options the desired insurance agent.
- Insurance Category: Choose from the available options for the client’s insurance category.
Beneath these two fields, you can input the client’s insurance number in the “Client Insurance Number” field.
Then click “Save“
For more details about adding a new client check the following guide “Add New Client“
Cases for Configuring
Insurance Category Settings and How Each Case Is Processed
Keep the following guidelines in mind to understand how the system calculates the co-payment for both the patient and the insurance company.
Case 1: No maximum payment or discount
In this case, where co-payment percentages are defined for both the client and the insurance company, without setting a maximum payment or discount, the system automatically divides the total cost of the service/product in proportion to the client’s and insurance company’s percentages.
For example:
Client: Ahmed (insured by the International Insurance Company – The First Category for International Insurance Company).
Product: Prescription Eyeglasses (with a cost of $500, categorized as a high-price product).
Co-payment Percentage: Client (30%), Insurance Company (70%).
Discount: None
Maximum Payment: None
Note and Explanation:
We notice that the system automatically charged Ahmed (150L.E) and the insurance company (350 L.E) in proportion to their co-payment percentages.
Case 2: There Is a Maximum Client Co-payment with No Discount
In this case, where a maximum client co-payment is set without specifying a discount, the system charges both the client and the insurance company according to their respective co-payment percentages. If the cost exceeds the maximum client co-payment limit, the system ensures not to exceed this limit by transferring the remaining portion of the total cost of the product or service to the insurance company.
Illustrative Example:
Client: Ahmed (insured by International Insurance Company).
Product: Prescription Eyeglasses (costing 500 L.E, categorized as high-priced products).
Co-payment Percentage: Client (30%), Insurance Company (70%).
Discount: None
Maximum Client Co-payment: Maximum co-payment of 100L.E. (for the client).
Note and Explanation:
We can see that the system charged Ahmed an amount that does not exceed the specified maximum co-payment limit (100L.E) when it was expected to charge her according to her co-payment percentage (150L.E). Meanwhile, the insurance company covered the remaining cost of the product (400L.E).
Case 3: There is a maximum insurance company contribution limit, and there is no discount
In this case, the system charges both the client and the insurance company according to their respective co-payment percentages. If the cost exceeds the maximum insurance company contribution limit, the system ensures not to exceed this limit by charging the remaining cost to the client.
Example for illustration:
Client: Ahmed (insured by International Insurance Company).
Product: Prescription Eyeglasses (costing 500 L.E, categorized as high-priced product).
Co-payment percentage: Client (30%), Insurance Company (70%).
Discount: None
Maximum payment limit: Maximum insurance company contribution limit of 200 L.E.
Note and Explanation:
In this scenario, you will notice that the system has charged the insurance company an amount that does not exceed the specified maximum contribution limit (200L.E) when it was expected to be charged according to its co-payment percentage (350L.E). Meanwhile, the client has been charged the remaining cost of the product (300L.E).
Case 4: There is a discount, and there is no maximum limit
In this scenario, where a discount is set for the client (typically, the discount is applied to the client and not the insurance company) without a maximum limit, the system loads the cost for both the client and the insurance company according to their respective co-payment percentages and then applies the discount to the client’s co-payment percentage.
Illustrative Example:
Client: Ahmed (insured by International Insurance Company).
Product: Prescription Eyeglasses (costing 500 L.E, categorized as a high-priced product).
Co-payment Percentage: Client (30%), Insurance Company (70%).
Discount: 10%
Maximum Payment Limit: None.
In this scenario, we observe the following:
- Client’s Co-payment: Ahmed’s co-payment would be 30% of 500L.E, which equals 150L.E.
- Insurance Company’s Co-payment: The insurance company’s co-payment would be 70% of 500L.E, which equals 350L.E.
- Discount Applied to Client’s Co-payment: With a 10% discount applied to the client’s co-payment, the final payment is reduced to 135 L.E.
- Insurance Company’s Payment: The insurance company covers the remaining cost after the discount, which is 350L.E.
Note and Explanation:
The system charged the insurance company (350L.E) by its specified co-payment percentage and charged the client (135L.E) after applying a discount (10%) to the client’s co-payment amount.
Case 5: There Is a Discount, and There Is an Insurance Company Maximum
In this case, where a discount is set for the client and an insurance company maximum is defined, the system loads the cost for both the client and the insurance company according to their co-payment percentages. If the insurance company’s co-payment exceeds the maximum, the excess over the maximum is charged to the client, and then the system applies the discount to the client’s co-payment percentage.
Illustrative Example:
Client: Ahmed (insured by International Insurance Company).
Product: Prescription Eyeglasses (costing 500 L.E., falling into the high-priced product category).
Co-payment percentage: Client (30%), Insurance Company (70%).
Discount: 10%
Insurance Company Maximum: 200L.E.
In this scenario, we observe the following:
– Client’s Co-payment: Ahmed’s co-payment would be 30% of 500L.E, which equals 150L.E.
– Insurance Company’s Co-payment: The insurance company’s co-payment would be 70% of 500L.E, which equals 350L.E.
– Exceeding Insurance Company Maximum: Since the insurance company’s co-payment exceeds the maximum of 200L.E, the excess (500L.E – 200L.E = 300L.E) is charged to the client.
– Client’s Payment After Exceeding Maximum: The client’s final payment includes the excess over the maximum plus the discounted co-payment, which equals 270L.E (300L.E – 10% discount).
– Insurance Company’s Payment: The insurance company covers up to the maximum contribution limit, which is 200 L.E.
Therefore, Ahmed pays 270L.E after the discount and the excess over the maximum, and the insurance company pays 200L.E.
Note and Explanation:
We can observe that the system only charged the insurance company (200L.E), adhering to the specified maximum co-payment for the insurance company. However, the system charged the client (270L.E), which is the sum of the client’s co-payment amount (150L.E) plus the excess over the client’s maximum co-payment (150L.E). Then, the system applied a discount percentage (10%) to the (300L.E), making the total cost payable by the client (270L.E).
Case 6: There Is a Discount and a Maximum for the Client
Here we encounter an issue when the client benefits from the maximum co-payment, as they will receive a discount due to not exceeding this limit, in addition to the discount allocated to them in the insurance category. According to common insurance practices, this situation is handled differently, and it will become clear in the following paragraphs.
Client: Ahmed (insured by International Insurance Company).
Product: Prescription Eyeglasses (costing 500 L.E, categorized as a high-priced product).
Co-payment percentage: Client (30%), Insurance Company (70%).
Discount: 10%
Maximum co-payment: Maximum co-payment of 100L.E (for the client).
Note and Explanation:
We noticed that the cost borne by the client is $100, which is the maximum co-payment. However, the cost borne by the insurance company is $388.88. Where does this number come from?
Let’s first discuss the case from a hypothetical perspective. The system was supposed to load the insurance company with $300 and the client with $200 based on the co-payment percentage for each. To avoid exceeding the maximum payment for the client, the system loaded an additional $100 on the insurance company (the value exceeding the maximum payment).
Therefore, the cost borne by the client is $100, and the cost borne by the insurance company is $400. This contradicts the result obtained, which divided the cost with the insurance company being $388.88.
For more details about the 6th case refer to this following article.