AmkaiOffice accommodates the trend among insurers to reimburse based on a flat rate, or “Case Rate,” for some cases with multiple procedures. When a procedure that would ordinarily fall under the Case Rate is performed, either the standard allowed rate or the Case Rate may be applied based on the negotiated contract.
To use Case Rates when creating or editing an insurance contract, select one of the primary types of contract from the current options and then set up the Case Rate procedures as “Carve Outs.” The contract can be set up as adjustment at time of charge or at time of payment or net.
A tab on the Contract Details screen enables you to define Case Rates for your organization. A Case Rate column has been added to the Procedures detail dialog. This column provides a drop-down menu that enables you to select a case rate to apply to a specific procedure when setting Carve-out Procedure rates for an insurance contract. The Case Rate Tab includes the following options:
A radio button labeled "Lesser of % of Billed Charges"
A radio button labeled "Lesser % of Allowed Amount"
A field labeled, “%” which enables you to enter a number representing the % of Billed or Allowed
The addition of the Case Rate option impacts billing procedures in the following ways:
The system takes into account the Case Rates when estimating a patient’s out of pocket expenses and when running costing reports.
If the option Lesser of % of Billed Charges has been selected for a Case Rate contract, the lower of the two rates will be applied for the case.
If the option Lesser of % Allowed Amount has been selected for a Case Rate contract, the lower of the two rates will be applied for the case.
If the option Include Supplies Billed in Case Rate is checked on the contract, the system will include the supplies billed/allowed amount when determining which is rate is to be used for billing. If this option is not checked, the system will bill supplies outside the Case Rate.
When posting charges with a contract set to take adjustments at time of payment for cases with procedures that have Case Rates associated to them, the system will apply a portion of the Case Rate to each procedure at the time of posting the payment.
Write offs would be calculated per line item using a weighted value (% of total charge per procedure).
When the Case Rate is applied, multiple procedure discounts are not applied.
If there are multiple Case Rate procedures in the same case, the highest case rate would apply.
When estimating revenue, the system applies the same rules as applied at the time of billing.
When running costing reports, the system applies the same rules as applied at the time of billing.
©2025 Surgical Information Systems. All Rights Reserved.