{"id":11004,"date":"2024-01-14T11:39:01","date_gmt":"2024-01-14T11:39:01","guid":{"rendered":"https:\/\/docs.daftra.com\/?post_type=user_manual&#038;p=11004"},"modified":"2025-10-05T10:11:24","modified_gmt":"2025-10-05T10:11:24","slug":"patients-with-discount-and-maximum-case-6","status":"publish","type":"user_manual","link":"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/","title":{"rendered":"Patients with Discount and Maximum (Case 6)"},"content":{"rendered":"<section class=\"wpb-content-wrapper\"><p>Here we encounter an issue when the patient 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 example.<\/p>\n<ul>\n<li>Patient: Anas (insured by International Insurance Company \u2013 First category of International Insurance Company).<\/li>\n<li>Service: Heart Surgery (costing 50,000 and classified as a high-priced product).<\/li>\n<li>Co-payment percentage: For the patient (40%), and the insurance company (60%).<\/li>\n<li>Discount: 10%<\/li>\n<li>\n<div class=\"group w-full text-token-text-primary border-b border-black\/10 gizmo:border-0 dark:border-gray-900\/50 gizmo:dark:border-0 bg-gray-50 gizmo:bg-transparent dark:bg-[#444654] gizmo:dark:bg-transparent\" data-testid=\"conversation-turn-161\">\n<div class=\"p-4 gizmo:py-2 justify-center text-base md:gap-6 md:py-6 m-auto\">\n<div class=\"flex flex-1 gap-4 text-base mx-auto md:gap-6 gizmo:gap-3 gizmo:md:px-5 gizmo:lg:px-1 gizmo:xl:px-5 md:max-w-2xl lg:max-w-[38rem] gizmo:md:max-w-3xl gizmo:lg:max-w-[40rem] gizmo:xl:max-w-[48rem] xl:max-w-3xl }\">\n<div class=\"relative flex w-[calc(100%-50px)] flex-col gizmo:w-full lg:w-[calc(100%-115px)] agent-turn\">\n<div class=\"flex-col gap-1 md:gap-3\">\n<div class=\"flex flex-grow flex-col gap-3 max-w-full\">\n<div class=\"min-h-[20px] flex flex-col items-start gap-3 whitespace-pre-wrap break-words overflow-x-auto\" data-message-author-role=\"assistant\" data-message-id=\"54b5d975-4f12-4570-b0b2-8454a56c4d4b\">\n<div class=\"markdown prose w-full break-words dark:prose-invert light\">\n<p>Maximum co-payment: Maximum co-payment of 10,000 (for the patient).<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"flex justify-between empty:hidden gizmo:justify-start gizmo:gap-3 lg:block gizmo:lg:flex\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter wp-image-39476 size-full\" src=\"https:\/\/docs.daftra.com\/wp-content\/uploads\/2024\/01\/5.jpg\" alt=\"\" width=\"768\" height=\"469\" srcset=\"https:\/\/docs.daftra.com\/wp-content\/uploads\/2024\/01\/5.jpg 768w, https:\/\/docs.daftra.com\/wp-content\/uploads\/2024\/01\/5-300x183.jpg 300w\" sizes=\"auto, (max-width: 768px) 100vw, 768px\" \/><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div><\/div>\n<div><\/div>\n<div>\n<p><strong><strong>Note and Explanation:<\/strong><\/strong><\/p>\n<p>We noticed that the cost borne by the patient is 10,000, which is the maximum co-payment. However, the cost borne by the insurance company is 38,888. Where does this number come from? Let\u2019s first discuss the case from a hypothetical perspective. The system was supposed to load the insurance company with 30,000 and the patient with 20,000 based on the co-payment percentage for each. To avoid exceeding the maximum payment for the patient, the system loaded an additional 10,000 on the insurance company (the value exceeding the maximum payment).<\/p>\n<p>Therefore, the cost borne by the patient is 10,000, and the cost borne by the insurance company is 40,000. This contradicts the result obtained, which divided the cost with the insurance company being 38,888.<\/p>\n<p>&nbsp;<\/p>\n<\/div>\n<\/div>\n<div class=\"group w-full text-token-text-primary border-b border-black\/10 gizmo:border-0 dark:border-gray-900\/50 gizmo:dark:border-0 gizmo:bg-transparent dark:bg-gray-800 gizmo:dark:bg-transparent\" data-testid=\"conversation-turn-162\">\n<h4 class=\"vc_custom_heading vc_custom_1698744247284\">Here is an explanation of what happened:<\/h4>\n<div class=\"wpb_text_column wpb_content_element \">\n<div class=\"wpb_wrapper\">\n<p>The system loaded the patient with a virtual cost, on which it applied a discount of 10% to make it exactly 10,000 (the maximum payment for the patient). It then subtracted this virtual cost from the total cost of the service (50,000) to calculate the cost borne by the insurance company.<\/p>\n<p>As shown on the invoice, (11,111) is the virtual cost, and the system derived this value using the following equation, where we denote the unknown with (C):<\/p>\n<ul>\n<li>C \u2013 0.1C (10% discount) = Maximum payment for the client (10,000)<\/li>\n<li>C \u2013 0.1C = 10,000<\/li>\n<li>0.9C = 10,000<\/li>\n<li>0.9C \u00f7 0.9 = 10,000 \u00f7 0.9<\/li>\n<li>\n<div class=\"group w-full text-token-text-primary border-b border-black\/10 gizmo:border-0 dark:border-gray-900\/50 gizmo:dark:border-0 bg-gray-50 gizmo:bg-transparent dark:bg-[#444654] gizmo:dark:bg-transparent\" data-testid=\"conversation-turn-167\">\n<div class=\"p-4 gizmo:py-2 justify-center text-base md:gap-6 md:py-6 m-auto\">\n<div class=\"flex flex-1 gap-4 text-base mx-auto md:gap-6 gizmo:gap-3 gizmo:md:px-5 gizmo:lg:px-1 gizmo:xl:px-5 md:max-w-2xl lg:max-w-[38rem] gizmo:md:max-w-3xl gizmo:lg:max-w-[40rem] gizmo:xl:max-w-[48rem] xl:max-w-3xl }\">\n<div class=\"relative flex w-[calc(100%-50px)] flex-col gizmo:w-full lg:w-[calc(100%-115px)] agent-turn\">\n<div class=\"flex-col gap-1 md:gap-3\">\n<div class=\"flex flex-grow flex-col gap-3 max-w-full\">\n<div class=\"min-h-[20px] flex flex-col items-start gap-3 whitespace-pre-wrap break-words overflow-x-auto\" data-message-author-role=\"assistant\" data-message-id=\"40180252-e67f-4c6f-abba-e7785b3cb7a8\">\n<div class=\"markdown prose w-full break-words dark:prose-invert light\">\n<p>C = 11,111<\/p>\n<p>&nbsp;<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter wp-image-39480 size-full\" src=\"https:\/\/docs.daftra.com\/wp-content\/uploads\/2024\/01\/9ijk-1.png\" alt=\"\" width=\"768\" height=\"469\" srcset=\"https:\/\/docs.daftra.com\/wp-content\/uploads\/2024\/01\/9ijk-1.png 768w, https:\/\/docs.daftra.com\/wp-content\/uploads\/2024\/01\/9ijk-1-300x183.png 300w\" sizes=\"auto, (max-width: 768px) 100vw, 768px\" \/><\/p>\n<\/div>\n<\/li>\n<\/ul>\n<div class=\"vc_row wpb_row vc_row-fluid\">\n<div class=\"wpb_column vc_column_container vc_col-sm-12\">\n<div class=\"vc_column-inner\">\n<div class=\"wpb_wrapper\">\n<div class=\"wpb_text_column wpb_content_element \">\n<div class=\"wpb_wrapper\">\n<p>&nbsp;<\/p>\n<p>So, (C) is the virtual cost that the system loaded for the patient, and then it subtracted it from the total cost of the service to calculate the cost borne by the insurance company:<\/p>\n<ul>\n<li>Insurance Company\u2019s Payment = Total Cost of the Service \u2013 Virtual patient Cost<\/li>\n<li>Insurance Company\u2019s Payment = 50,000 \u2013 11,111 = 38,888<\/li>\n<\/ul>\n<p>The system processes this equation as explained to avoid applying the discount after applying the maximum payment.<\/p>\n<p>&nbsp;<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"vc_row wpb_row vc_row-fluid\">\n<div class=\"wpb_column vc_column_container vc_col-sm-12\">\n<div class=\"vc_column-inner\">\n<div class=\"wpb_wrapper\">\n<div class=\"wpb_text_column wpb_content_element \">\n<div class=\"wpb_wrapper\">\n<div class=\"post-inner-content\">\n<div class=\"entry-content\">\n<div class=\"group w-full text-token-text-primary border-b border-black\/10 gizmo:border-0 dark:border-gray-900\/50 gizmo:dark:border-0 bg-gray-50 gizmo:bg-transparent dark:bg-[#444654] gizmo:dark:bg-transparent\" data-testid=\"conversation-turn-169\">\n<div class=\"p-4 gizmo:py-2 justify-center text-base md:gap-6 md:py-6 m-auto\">\n<div class=\"flex flex-1 gap-4 text-base mx-auto md:gap-6 gizmo:gap-3 gizmo:md:px-5 gizmo:lg:px-1 gizmo:xl:px-5 md:max-w-2xl lg:max-w-[38rem] gizmo:md:max-w-3xl gizmo:lg:max-w-[40rem] gizmo:xl:max-w-[48rem] xl:max-w-3xl }\">\n<div class=\"relative flex w-[calc(100%-50px)] flex-col gizmo:w-full lg:w-[calc(100%-115px)] agent-turn\">\n<div class=\"flex-col gap-1 md:gap-3\">\n<div class=\"flex flex-grow flex-col gap-3 max-w-full\">\n<div class=\"min-h-[20px] flex flex-col items-start gap-3 whitespace-pre-wrap break-words overflow-x-auto\" data-message-author-role=\"assistant\" data-message-id=\"36daaca1-da59-4b6f-817d-4b661a4760df\">\n<div class=\"markdown prose w-full break-words dark:prose-invert light\">\n<p>With this tutorial and the previous ones, we have reached the end of the Medical Insurance Guide for Medical Clinics. We have learned how to add a new insurance company to the account, add an insurance category or class to it, link the patient to an insurance company and a specific insurance category, and the mechanism for processing insurance category rules.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/section>","protected":false},"author":23,"template":"","categories":[5044],"tags":[],"class_list":["post-11004","user_manual","type-user_manual","status-publish","hentry","category-medical-clinics"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v17.8 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Patients with Discount and Maximum (Case 6) - Daftra Knowledge Base<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Patients with Discount and Maximum (Case 6) - Daftra Knowledge Base\" \/>\n<meta property=\"og:description\" content=\"Here we encounter an issue when the patient 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 [&hellip;]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/\" \/>\n<meta property=\"og:site_name\" content=\"Daftra Knowledge Base\" \/>\n<meta property=\"article:modified_time\" content=\"2025-10-05T10:11:24+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/docs.daftra.com\/wp-content\/uploads\/2024\/01\/5.jpg\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"3 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebSite\",\"@id\":\"https:\/\/docs.daftra.com\/#website\",\"url\":\"https:\/\/docs.daftra.com\/\",\"name\":\"Daftra Knowledge Base\",\"description\":\"Daftra\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/docs.daftra.com\/?s={search_term_string}\"},\"query-input\":\"required name=search_term_string\"}],\"inLanguage\":\"en-US\"},{\"@type\":\"ImageObject\",\"@id\":\"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/#primaryimage\",\"inLanguage\":\"en-US\",\"url\":\"https:\/\/docs.daftra.com\/wp-content\/uploads\/2024\/01\/5.jpg\",\"contentUrl\":\"https:\/\/docs.daftra.com\/wp-content\/uploads\/2024\/01\/5.jpg\",\"width\":768,\"height\":469},{\"@type\":\"WebPage\",\"@id\":\"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/#webpage\",\"url\":\"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/\",\"name\":\"Patients with Discount and Maximum (Case 6) - Daftra Knowledge Base\",\"isPartOf\":{\"@id\":\"https:\/\/docs.daftra.com\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/#primaryimage\"},\"datePublished\":\"2024-01-14T11:39:01+00:00\",\"dateModified\":\"2025-10-05T10:11:24+00:00\",\"breadcrumb\":{\"@id\":\"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/docs.daftra.com\/en\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Patients with Discount and Maximum (Case 6)\"}]}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Patients with Discount and Maximum (Case 6) - Daftra Knowledge Base","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/","og_locale":"en_US","og_type":"article","og_title":"Patients with Discount and Maximum (Case 6) - Daftra Knowledge Base","og_description":"Here we encounter an issue when the patient 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 [&hellip;]","og_url":"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/","og_site_name":"Daftra Knowledge Base","article_modified_time":"2025-10-05T10:11:24+00:00","og_image":[{"url":"https:\/\/docs.daftra.com\/wp-content\/uploads\/2024\/01\/5.jpg"}],"twitter_card":"summary_large_image","twitter_misc":{"Est. reading time":"3 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebSite","@id":"https:\/\/docs.daftra.com\/#website","url":"https:\/\/docs.daftra.com\/","name":"Daftra Knowledge Base","description":"Daftra","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/docs.daftra.com\/?s={search_term_string}"},"query-input":"required name=search_term_string"}],"inLanguage":"en-US"},{"@type":"ImageObject","@id":"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/#primaryimage","inLanguage":"en-US","url":"https:\/\/docs.daftra.com\/wp-content\/uploads\/2024\/01\/5.jpg","contentUrl":"https:\/\/docs.daftra.com\/wp-content\/uploads\/2024\/01\/5.jpg","width":768,"height":469},{"@type":"WebPage","@id":"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/#webpage","url":"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/","name":"Patients with Discount and Maximum (Case 6) - Daftra Knowledge Base","isPartOf":{"@id":"https:\/\/docs.daftra.com\/#website"},"primaryImageOfPage":{"@id":"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/#primaryimage"},"datePublished":"2024-01-14T11:39:01+00:00","dateModified":"2025-10-05T10:11:24+00:00","breadcrumb":{"@id":"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/docs.daftra.com\/en\/user_manual\/patients-with-discount-and-maximum-case-6\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/docs.daftra.com\/en\/"},{"@type":"ListItem","position":2,"name":"Patients with Discount and Maximum (Case 6)"}]}]}},"_links":{"self":[{"href":"https:\/\/docs.daftra.com\/en\/wp-json\/wp\/v2\/user_manual\/11004","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/docs.daftra.com\/en\/wp-json\/wp\/v2\/user_manual"}],"about":[{"href":"https:\/\/docs.daftra.com\/en\/wp-json\/wp\/v2\/types\/user_manual"}],"author":[{"embeddable":true,"href":"https:\/\/docs.daftra.com\/en\/wp-json\/wp\/v2\/users\/23"}],"version-history":[{"count":6,"href":"https:\/\/docs.daftra.com\/en\/wp-json\/wp\/v2\/user_manual\/11004\/revisions"}],"predecessor-version":[{"id":39482,"href":"https:\/\/docs.daftra.com\/en\/wp-json\/wp\/v2\/user_manual\/11004\/revisions\/39482"}],"wp:attachment":[{"href":"https:\/\/docs.daftra.com\/en\/wp-json\/wp\/v2\/media?parent=11004"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/docs.daftra.com\/en\/wp-json\/wp\/v2\/categories?post=11004"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/docs.daftra.com\/en\/wp-json\/wp\/v2\/tags?post=11004"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}