This guide explains the relationships between payers, items and fees and how they work together for billing. The sections describe each component in the order they would be used when setting up a new payer.
Medicare's items and fees provide the healthcare system with a standard list of services and values (costs). A Fee Type is used by other payers (e.g. funds) and providers (e.g. specialists) to apply their own values to that list of services. These Fee Types are given a P-code, which can be viewed in the Item Details screen. You can create a custom code with a meaningful description in the Item Fee Codes screen.
Item Fees Codes are added in Practice Setup > Items > Item Fee Codes
To learn more, see the Add a new fee type guide.
A payer is a person or entity paying a patient's bill. This payment can be via a claim (Medicare, DVA, health fund) and by billing the patient or a third party (TAC, Worksafe or Workcover). A payer must be set up in Zedmed before they can be selected as a patient's payer and appear on an invoice.
In Zedmed, a patient's payer will show as:
- Medicare or DVA - if the invoice is being paid via a government claim or rebate.
- The patient - if the invoice is being paid by the patient or the patient's health fund (claim).
- A 3rd Party - if the invoice is being sent to another payer.
New payers are added in Management > Debtors > Account Payer - New Account Payer.
When adding a Health Fund, you will need to add the ECLIPSE scheme to each specialist's profile
To learn more, see the Create a new payer guide.
All Medicare items and their fees are uploaded into Zedmed. Medicare adds new items as it provides new services, using the fees file upload. Medicare item numbers are used by other claim payers like funds who assign their own values for the services. Payers and practices can add their own unique items using the Item Details screen.
New Medicare items are added in Management > Practice setup > Items > Update/Load MBS Fees
Non-Medicare items are added in Management > Practice setup > Items > Item Details
A Fee is the value assigned to a service item, and different payers have different fees for the same items. For example, Medicare, Health Funds and 3rd Parties like WorkCover have their own fee schedules for the services they cover. Private practitioners will also have a value that they charge for a service.
- Medicare Fee changes are applied at the start of each month by uploading the Medicare Fees File. Learn more.
- Health Funds and other payers publish their own Fees Files, which are uploaded as they become available. Learn more.
- Some specialists will have their own charge for a service item, which is manually maintained. Learn more.
Medicare fees are uploaded in Management > Practice setup > Items > Update/Load MBS Fees
Non-Medicare fees are uploaded in Management > Practice setup > Items > Update Other Fees
Fees can be manually entered in Management > Practice setup > Items > Item details.
The Item Details screen is a key area in Zedmed as it shows, for a selected service Item Number, the fees set by the different payers and providers. There are set fields for payers like Medicare/DVA and insurers, and open fields (P1, P2 etc) that providers can use to enter their fees. Any custom Fee Type you create is added here with its Description (E.g Acme Insurance). The fee values can be uploaded using fee files or manually added, for example, if specialists have different charges for the same Item.
An item's payer and fees are viewed in Management > Practice setup > Items > Item details.
To learn more, see the Managing Item Fees guide.
A patient can have multiple payers, including themself, added to their patient record. The payer shown is the default and will be the default payer on an invoice. How a payer is added is slightly different for different payers due to the information required. If a payer is a Health Fund, the patient will be selected as the payer and the fund will appear for billing on the invoice.
To add a payer, open the patient record, and from the Payers section, select Add and follow the screens.
When you create an invoice, it will show the default payer. When you add an item to the invoice, the payer's default Fee Code will be shown and determine the value of the service item. In the screenshot below, the default payer is Acme Insurance, and the default Fee type is ACM.
A new invoice is usually created from the Waiting Room by right-clicking the patient and selecting Bill.