Insurance and Contracts
Somebody other than the patient pays part of the bill: an insurance company, a syndicate, a company you contracted with, a union fund. Every clinic of any size has two or three of them, and each has its own rates and its own rule about who pays what.
Today that lives on a laminated sheet at reception. The Insurance and contracts plugin puts it in the system: the party, the agreement, and the price list the agreement prices your own services at.
The whole cycle is here
The agreement, the visits charged against it, the monthly claim, the payment the company sends back, and the lines it refuses. What is not here is sending the claim electronically to any company's own system — every claim leaves this system as your own printed sheet or a spreadsheet.
Where to Find It
| Screen | Address |
|---|---|
| Insurance & payers | /payers |
| Claims | /payer-claims |
| Payer dashboard | /payer-dashboard |
| Plugins | /plugin-settings |
It appears under Money in the menu once the plugin is on, as two rows: Register a payer and the list itself.
Switching It On
Settings → Plugins → Insurance and contracts.
It is off for a new clinic, and switching it on builds what it needs — a few seconds, then the Insurance & payers screen appears. Because the coverage split shows on the invoice, it also switches Invoices on if you had it off.
Switching it off later hides everything and deletes nothing: every payer, contract and agreed price is exactly where you left it when you switch it back on.
The Payer
A payer is whoever pays instead of the patient. You classify it — insurance company, syndicate, company, fund — and the system treats all four the same way, because everything that actually differs between them is on the contract.
Register one with its Arabic name (that is what prints), and whatever you have of a contact person, a phone and an email.
The screens
The payers list reads like every other list in the system: search, filter by type or by whether the payer is still in use, sort, and a menu on each row. Every row opens the payer's own page.
| To | Go |
|---|---|
| Register a payer | New payer, which opens a form of its own |
| Read one | Click the row, or View in its menu |
| Change its details | Edit on the page or in the row's menu — again a page, not a box over the list |
| Stop offering it | Switch off |
| Remove it | Delete, offered only where it can be done |
Its page carries three tabs: the payer's details, its contracts with the price list of the one you are reading, and Activity log — who registered it, who changed what, and when.
Switched off, or deleted
A payer you stop working with is switched off. Its agreements and prices stay readable, which is what lets you answer a question about last year.
Delete is offered only for a payer nothing has been agreed with yet — one registered by mistake, or a duplicate. As soon as a payer carries a contract or a patient's card the delete disappears, and asking for it anyway is refused: a visit charged under an agreement must keep reading the agreement it was charged under.
The Contract
The agreement itself: when it starts, when it ends, and who pays what.
| Field | What it is for |
|---|---|
| Contract number | The company's own reference, so you can quote it on the phone |
| Starts / Ends | The window it is in force. Leave the end empty for an open-ended agreement |
| Coverage rule | Who pays what — see below |
| Requires an approval number | Whether the desk must type an approval before a covered visit can be charged |
| Payment terms | How many days the company has to pay, which the claim's ageing will read |
The coverage rule
Three shapes, and the screen reads each of them back as a sentence:
- A percentage the payer carries — «تتحمل الجهة ٨٠٪ من قيمة الخدمة، ويتحمل المريض الباقي.»
- A fixed co-pay the patient carries — «يتحمل المريض ٥٠ ج.م عن كل زيارة، وتتحمل الجهة الباقي.»
- Full coverage — the payer carries the whole service.
A co-pay bigger than the visit is not a debt: the patient pays the visit, and the payer carries nothing.
One agreement at a time
A payer cannot have two contracts covering the same day. Try it and the system refuses and names the agreement that is in the way, because otherwise a visit would have two prices to choose from and nothing to decide between them.
Renegotiating
When rates change you do not edit last year's contract. Open the old one and use Renew with the same prices: you get a new agreement, with new dates and every price copied in ready to edit.
The old one keeps its own list, untouched. That is the whole point — a visit charged under it must keep reading the price it was charged at.
An expired contract is not a deleted one
It stays on the payer, marked as expired, with its price list intact. It is history, and history is what you need when a company queries an old claim.
The Price List
Each contract prices your own services — the same ones you sell and invoice everywhere else, from Products and Services. You do not type a second catalogue.
Add a service to the list and the row reads three figures: your own price, the contracted price, and the difference between them.
| Your price | Contracted | Difference |
|---|---|---|
| 500 | 300 | 200 |
A service the contract does not price
A service that is not on the list is not covered: the patient pays your own price for it in full. That is deliberate — a company reimburses what it agreed to reimburse, and a service nobody agreed a price for is not that.
Excluding one service
Sometimes the agreement covers 80% of everything except radiology. Set that one row's rule to not covered, and it is charged wholly to the patient while the rest of the contract carries on covering 80%.
The same field is how you cover one service differently — a contract at 80% with implants at 50%.
Prices you change later
Raising a price changes what the next visit is offered and nothing that has already been agreed. Prices are only ever read forward.
The Patient's Card
Patient file → Insurance cards.
A card is what the patient hands over at reception: the payer, the membership number, the class if the contract has classes, and the expiry printed on it.
A patient may hold two — a company card and a syndicate card — and which one a visit goes on is chosen per visit. One of them is the default, which is only what the desk is offered first.
An expired card is a warning, not a wall
The system says the card lapsed and names the date, and lets you carry on. Companies renew weeks after the plastic says otherwise, and you are the one who can ring them.
Deleting a card changes nothing that has already been charged: every covered visit keeps its own copy of the payer, the contract, the approval and the split.
The Covered Visit
On the visit — or the session, or an invoice you raised by hand — pick the payer. The patient's default card fills it in for you.
Three figures then appear, each labelled:
| Total | What the visit is worth. This is what the clinic earned |
| Payer carries | What the company owes you |
| Patient carries | What you collect at the desk |
And under them, the only number the receptionist acts on: collect now.
A visit whose patient share is paid in full reads as paid — because it is, as far as the desk is concerned. The company's half is shown separately as owed by them.
The approval number
Where the contract says an approval is required, the visit will not be charged without one, and the system names the contract that is asking. Where the contract does not, the field is not even shown.
A service the contract does not cover
On a visit carrying a covered consultation and an excluded panoramic, the panoramic is charged to the patient in full and marked as uncovered, while the consultation is still split 80/20. One visit, two answers, because that is what the agreement says.
The split never moves
The three figures are written when the visit is charged, together with the rule that produced them. Renegotiate the contract next month and last month's visits still read exactly what they were charged at — that is the point of writing them down rather than working them out again each time.
Correct a covered visit's price and it is re-split by the rule that was in force the day of the visit, not by today's.
What This Does to Your Money Screens
Three figures that used to be one, and must never be blended again:
- Cash collected — what patients actually handed over. The company's share is never written here.
- Revenue — the whole of what you earned, on the day you earned it.
- Owed by insurers and payers — a tile of its own on the cash flow report, and its own account in the ledger (
1110, separate from patient debts on1100).
It is not takings until they pay
A covered visit earns you the full amount on the day of the visit and puts only the patient's share in the till. Reading the two as one number is exactly the mistake this feature exists to end.
Switching It Off With Covered Visits
Everything is hidden and nothing is deleted. Each covered visit falls back to reading as an ordinary one — the whole of it the patient's — and every stamped split is waiting when you switch it back on.
The Claim
At the end of the month you ask each company for what it owes. That is a claim: one sheet, one payer, one period, and every covered visit on it that you have not asked for before.
Building one
Claims → Build a claim. Pick the payer and the dates, and everything charged to that payer inside them that has never been claimed is gathered onto a draft.
The dates choose what to gather. They are not what defines the claim — what defines it is unclaimed. So a visit charged the day after you sent September's claim does not sneak onto a sheet the company already has: it waits for October's, and appears there.
Build the same month twice and the second one tells you there is nothing left to ask for. That is the honest answer, and it is also what stops two people at the desk from claiming the same visit twice.
Holding a line back
A draft is still yours. A line missing its approval number can be held back: the claim total drops, and the visit returns to the pool to be claimed next month once the approval exists.
The reverse works too — anything unclaimed inside the period is offered under the lines, and can be added before the claim goes out. That list is also where a visit refused last month comes back, marked as claimed before, once you have fixed whatever got it rejected.
Sending it
Mark as submitted, with the date it went and the reference the company gave you.
Nothing is transmitted anywhere. Two things change, and both matter:
- the lines are fixed from that moment, because the sheet is in somebody's hands and the record must not disagree with the paper;
- the clock starts. The due date is worked out from the payment terms on the contract as they stand that day and written down. Renegotiating terms next year cannot re-date a claim you sent this year.
Then print it — on a sheet you can edit yourself, in Print templates — or export it as a spreadsheet, since every company asks for its own columns.
Getting Paid
Record a payment with the amount, the date it arrived and the cheque or transfer reference. A claim can take several: companies pay in instalments and you have to be able to say which cheque was which.
A payment bigger than what the claim still has outstanding is refused. The excess belongs to another claim and has to be recorded there, or you lose track of which one was actually paid.
The short payment
The cheque is usually smaller than the claim. This is the part the system will not let you skip.
Against a claim of 12,000 the company sends 10,500. The screen shows 1,500 as unexplained, and the claim cannot be closed while that figure stands. You go down the lines and say, for each one, what the company did: accepted, short paid, or rejected.
That is deliberate. The system will not guess how the shortfall spreads across the lines, because companies do not short-pay evenly — they refuse specific visits for specific reasons, and which visits they were is the only thing worth knowing next month.
The rejection
A rejected line needs a reason, from a list you own: no prior approval, service not covered, member not covered, claim submitted late, other. Reword them to match what your payers actually say — a list nobody recognises is a list where everything ends up filed under "other".
Then the money has to go somewhere, and there are three answers:
| What happens | |
|---|---|
| Bill it to the patient | Their balance rises by that amount against that same visit, and the visit stops reading as paid. The debt moved from the company to the patient; nothing was created |
| Write it off | It leaves what the company owes and is reported as a write-off. The patient is never asked for it |
| Fix it and claim again | Nobody pays yet. The visit goes back into "earned, never claimed" and is offered on the next claim you build — for the refusals you can actually fix, such as an approval you have since obtained |
Only the third one puts the visit back in the pool. A share the patient is already carrying, or one you have written off, is finished and is never offered on another claim — otherwise you would be asking the company for money that has already been accounted for somewhere else.
Whichever you choose, the split stamped on the visit does not move. The visit was 300, the company's share was 240, and it stays that way on the record and on the claim — because a claim that quietly rewrote itself is a claim you cannot argue about six weeks later.
A write-off is not a reversal of revenue
The visit was worth 300 on the day you did the work, whoever later refused to pay for it. So a write-off is an expense (account 5700), not money removed from a month you have already reported.
What Each Payer Owes
The payer's page → Statement. Seven figures over any period you choose:
| Earned, never claimed | Work you have done and never asked for. The easiest money in the system to collect |
| Claimed | Asked for |
| Collected | Actually arrived |
| Billed back to patients | Refused, and moved onto the patient |
| Written off | Refused, and given up on |
| To be claimed again | Refused, and going back out on the next claim |
| Still owed | Claimed, not paid, and not settled another way |
Underneath, that last figure by how late it is: within terms, up to 30 days late, 31–60, more than 60 — each claim aged against the date it was due, not against today's contract.
The Payer Dashboard
Four panels, in the order worth acting on:
- Earned and never claimed — by payer, oldest first. This one is entirely your own doing, and it is usually the biggest number on the screen the first time it is opened.
- Claims past their due date — who is late, and by how many days.
- What each payer refused this month — as a rate, not a total: a company refusing 4,000 out of 200,000 is not the problem, and one refusing 4,000 out of 6,000 is.
- Claims with lines nobody has answered — money that came back with no explanation recorded against it.
A submitted claim that passes its due date also raises a notification, once.
Who Can Do What
| To | You need |
|---|---|
| Read the payers, their contracts and the agreed prices | Insurance & payers: view |
| Register a payer, open a contract, price it | Insurance & payers: manage |
| Record a card on a patient's file | Edit patients |
| Put a visit on a contract | The same permission as changing that visit's money |
| Build, submit and settle claims | Insurance claims |
| Reword the rejection reasons | Insurance & payers: manage |
Reading is separate on purpose: the desk needs to see an agreed price without being able to change one. Claiming is separate for a sharper reason — settling a claim can raise a patient's balance, so it belongs to whoever handles the clinic's money, not to whoever books the visits.
Related
- Products and Services — the catalogue a contract prices
- Taking Payments
- Accounting — where the payer receivable (1110) and write-offs (5700) live
- Print templates — the claim sheet you hand the company
- Plugins