Estimated insurance value for a planned stay. What the patient could be responsible for, and what the insurer will probably pay, worked day by day across every level of care in the step-down.
Start from a finished VOB, or enter the benefits yourself.
The Output
The cumulative deductible, copay and coinsurance across the planned stay, capped at the out-of-pocket maximum. A dollar figure rather than a percentage.
What the plan is likely to pay across the same stay, carried as a low-to-high range rather than a single number, so the spread stays visible.
Patient responsibility is front-loaded and capped. The estimate shows the day the out-of-pocket maximum is reached, after which the plan carries the full allowed amount.
Open the detail and read the stay one day at a time, level of care by level of care, with the running totals for both sides.
The Gap It Closes
| What the verification tells you | What the estimate tells you |
|---|---|
| A deductible, a coinsurance percentage, an out-of-pocket maximum | The same three figures, applied day by day across the whole stay |
| The patient's share as a percentage | The patient's share as a dollar amount, capped where the plan caps it |
| Nothing about how long the stay will run | Your facility's own typical stay at that level of care, or an editable default |
| Nothing about the allowed amount | An allowed amount per day from adjudicated claims, or your own rates |
| No total | Two totals that sum to the allowed amount |
The Order of Operations
Day by day, in step-down order, through detox, residential, PHP and IOP, or the mental health track of RTC, PHP and IOP. The sequence is the same every time:
Patient responsibility and expected plan payment always sum to the allowed amount. Amounts billed above the allowed amount are not included, because a balance bill is a collections question rather than a benefits one.
The Inputs
Pick a finished VOB and the deductible, coinsurance, out-of-pocket maximum and copay populate from it, in network or out. Without one, start from what Plan Fine Print reports for the plan, or enter them by hand.
PayerLenz reimbursement benchmarks for that payer, facility state and network. Blue plans require the alpha prefix, because without it every Blue plan in the state gets blended into one number.
Typical is the default. Rerun at the 25th percentile, the median or the 75th, and the plan figure carries the low-to-high spread rather than hiding it.
U&C, MNRP, MRC1, MRC2 and NAP stay separate, because the same payer can pay very differently under two of them. The estimate uses the method recorded on the VOB. With no VOB selected it falls back to the method Plan Fine Print reports for that plan, and then to the method with the most claims behind it. It only considers methods that actually have rates at that payer, state and network.
Your facility's own typical stay at that level of care, once it has five or more discharged stays there. Otherwise a platform default, shown on screen and editable.
A stay that crosses into a new plan year resets both the deductible and the out-of-pocket maximum. The estimate applies the reset mid-stay.
Two Things It Flags
Some out-of-network plans issue the check to the subscriber rather than the facility. The expected payment figure does not change. The probability of collecting it does, and that belongs in the admissions conversation rather than in the billing follow-up six weeks later.
When a VOB reports that the plan carries no out-of-network benefit, the estimate flags it right above the numbers and still runs the math.
Both figures are estimates. The actual length of stay is not known at admission, and neither is what the payer will allow and pay for each date of service. Neither number is a verification of benefits and neither is a guarantee of payment. Real numbers can come in higher or lower.
Estimated insurance value. It is the estimated value of a planned stay to the facility and to the patient: what the patient could owe, and what the plan will probably pay.
No. The actual length of stay is not known at admission, and neither is what the payer will allow and pay for each date of service. Both figures are estimates, and real numbers can come in higher or lower. The estimate is not a verification of benefits.
Yes. Start from what Plan Fine Print reports for the plan, or type in the deductible, coinsurance, out-of-pocket maximum and copay yourself. A finished VOB simply saves the typing and keeps the estimate tied to a record.
PayerLenz reimbursement benchmarks for that payer, facility state and network, built from adjudicated behavioral health claims. You can enter your own rates instead at any point, and the arithmetic runs the same way.
Yes. Both the deductible and the out-of-pocket maximum reset on the first day of the new plan year, and the estimate applies the reset mid-stay. A patient can be exposed to close to two full out-of-pocket maximums for one continuous episode of care.
No. Customers only ever see their own VOBs.