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When a patient’s HMO covers part of their bill, Bill HMO splits the bill once: the insurer’s share becomes a draft claim, and the patient pays only their share. The insurer’s share is never recorded as cash you have received.

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Where you will find it

  • Payments page — under Payment Method, once a patient with an insurer on file is selected.
  • Collect payment sheet on a pharmacy or laboratory row — beside the payment method.
  • A patient’s Billing tab — Bill HMO on an invoice’s Actions menu.
For clinics set to Outside the US, Insurance is no longer a payment method: billing the insurer is Bill HMO, and the patient’s share is paid with Cash, Card, Bank Transfer, Mobile Money or Other.

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Bill the insurer

1

Choose the patient and tick what they are paying for

On Payments, select the patient and tick their pending items. On Collect payment, the items for that row are already ticked.
2

Select Bill HMO

The sheet names the insurer, the plan and member number, and says what percentage of each item the patient pays. Each item shows Price (the insurer’s tariff where one applies), Insurer pays and Patient pays, with the totals underneath.
3

Confirm

Select Bill followed by the insurer’s name and amount. You are told which draft claim was created and what the patient pays.
4

Collect the patient's share

The same items come back showing only the patient’s share. Collect it as you would any payment. Tax and fees are never billed to the insurer; they are added to the patient’s payment.
On a patient’s Billing tab the invoice shows HMO billed with the amount, its balance drops to the patient’s share, and the invoice reads Paid once the patient has paid that share.

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What the insurer is billed

  • The price on the claim. Each item goes on the claim at the insurer’s agreed price from its price list when one matches by code or name and its dates are in force, and at your own price otherwise. The insurer’s share is that price less the patient’s percentage, and the patient pays their percentage of the same price. When the agreed price is lower than yours, the difference is not billed to anyone, and the sheet says the share is worked out on the insurer’s tariff. An agreed price higher than yours is not used.
  • No co-payment recorded, or 100 percent. If the patient’s plan has no co-payment recorded, they pay in full and there is nothing to bill, so the sheet tells you to add it to their insurance details first. A plan where the patient pays everything has nothing to bill either.
  • Paid already. If the patient has already paid their share in cash, billing the insurer afterwards gives the same split. The order of the two does not matter.
  • Billing twice. Billing the same items again does not create a second claim; you are told they are already billed.
  • Same day, same insurer. More items billed for the same patient and insurer on the same day join the same draft claim.

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Review and send the claim

The claim is a Draft in Claims. Check the lines and send it when you are ready. When the insurer pays, record the payment.

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On the receipt

A receipt for items billed to an insurer has a Billed to HMO section with the insurer’s name and amount, and a Patient portion line, so the patient can see what the insurer is paying.

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Who can do this

Billing the insurer is part of taking the payment, so it follows the Collect payments permission. You can switch it on or off for a person in their Permissions sheet. Owners and managers can always do it.

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Check it worked

  • The items on Payments now show only the patient’s share, or disappear if the insurer covers all of it.
  • Claims has a Draft claim for the insurer with the same items.
  • On the lab, pharmacy and imaging lists the item’s payment badge reads Paid · HMO pending once the patient has paid their share and the insurer’s part is outstanding.
  • The insurer’s share is not in your takings. It appears in HMO receivables once the claim has been sent.

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Common issues

The patient needs an insurer on file, and your clinic’s Insurance setting must be Outside the US. Clinics set to the US keep the Insurance payment method.
Their insurance may have expired, or needs checking. Update it on the patient’s profile, then try again.
The patient paid for this visit themselves and asked that their HMO not be told, and your clinic recorded that on their Security tab under Services not shared with the health plan. Bill HMO will not make a claim for any item whose service dates fall inside that restriction, and nothing is changed. Take the patient’s payment as usual. If the patient changes their mind, an owner or manager ends the restriction there, and you can bill the HMO again. Services not shared with the health plan
Someone paid or cancelled an item since the list loaded. Refresh the list and try again.
A declined claim no longer counts as billed to the insurer, so the items come back on the patient’s list at their full balance.