Service Rates

Service Rates monitor cases where the expected or billed amounts differ from the standard rate or when a payer or patient agreement necessitates overriding the usual rate for a specific service, such as in single-case agreements SCAs).

User Permissions

Managing Organization and Organization users will need edit-level permissions enabled under the Patients section of their user profile. Managing Organization and Organization Admin profiles requires no additional configuration to create and manage a service rate. For more information on user permissions, click here.

Create a Service Rate

Service rates are created within the U/R tab of the patient's treatment episode. Let's review the process together.

1. Navigate to the Patients section.
   
2. Locate the desired patient and click the U/R quicklink.
   

3. Next, click the Service Rates subtab.

   

4. Then click Add Service Rate.
   
5. The Service Rate Type drop-down will default to Insurance - Single-case Agreement. Update the field to one of the following when applicable:
   • Private Pay: Use this type when utilizing the EMR integration to bill a patient as private pay or when a special rate of service has been established with the patient.
   • Standalone Authorization: Use this type to include an authorization number when recording a standalone service. Note: unlike traditional authorization (U/R) plans, standalone authorizations with a pending status can submit claims without issue.
     
6. Next, enter the start date and end date of the agreement.
   
7. Then select the Facility from the drop-down to generate the service list.
   
8. Update the Service field before selecting the billing profile.
   
9. Then select the payer name from the drop-down.
   
10. Toggle on Overrides Facility Service Rate on Claims to instruct the system to use the rate established in the Single Case Agreement.
    
11. Next, update the Rendering Provider and Billing Provider fields.
    
12. Enter the unit rate and include any pertinent notes when applicable.
    
13. Finally, click Add to complete the process.
    

Service Rate Overrides

When a patient’s claims require a non-standard charge amount for a service, use a service rate override to specify the new charge. Service rate overrides will only successfully set a claim charged amount if all the following conditions are met.

1. The service rate information must exactly match the utilization plan or attendance calendar (for standalone services) configuration. This information includes date range, facility, service, service billing profile, payer, rendering provider, and billing provider.
   • If no information changes, one service rate override can be entered for multiple U/R plans spanning different date ranges. The service rate's start date would be the start date of the first UR plan for the service. The end date of the service rate would be the last date of the final UR plan for that service. If any information changes, the override will not be applied to the service.
   • Example: The rendering provider in the U/R tab is Dr. Phillips. The rendering provider in the Service Rates tab is set as Dr. Smith. In this situation, this override will fail, and the standard service rate will be charged.
2. All rules impacting the claims agree with the information in the U/R plan, the Attendance Calendar, and the Service Rates tab.
   • Example: There is a claim rule set to change the billing profile to PHP-H0035, H0035 but the Service Rates tab and UR plan list the billing profile as PHP-H2036. This override will not occur for the service.
3. The unit rate entered in the Add Service Rate dialogue box must be greater than the rack rate (e.g., the unit rate should exceed the insurance contracted rate for the service). Rack rates are set within each billing profile in Practice Admin > Facilities. If the unit rate entered is lower than the rack rate, the override will fail.
   • Tip: When service rate overrides are often needed for a particular service, make a new billing profile for this specific situation. The rate associated with the billing profile can be set to $1. This behavior ensures that the rate set in the Add Service Rate dialogue will always be greater, allowing the override to take effect. For more information on creating services, click here.

How Do Service Rates (Single Case Agreements) Impact Reporting?

Let's review some common reporting questions related to service rates.

• When a service rate is entered at the patient level (e.g., single case agreement), it overrides the facility or payer rates in the Expected Amount field in reports like the Claim Status Report (by Service Date or by Claim).
• In the Claim Status Report, you can use the filter Has Single-Case Agreement, so you can easily identify patients with a single-case agreement. This is useful to analyze whether the payer has paid what was agreed upon. Report results will display Yes or No, with Yes indicating the patient has a Service Rate (Single Case Agreement) added to their treatment episode.
• The Daily Census Report will also indicate if a patient has a single case agreement.