One visit, two bills: billing the insurer and the patient

An insured patient's visit has two parties paying for it: the patient pays their share at the desk, and the insurer or employer pays the rest later. It looks simple until the end of the month, when the insurer has paid less than you billed, the patient says they paid what they were asked, and nobody knows where the difference went.

Most of those gaps do not start in the claims office. They start when the bill is raised: a price that does not match the insurer's contract, a co-payment worked out on the wrong amount, a discount applied to both sides. This guide explains how to set up two-party billing from the start. What comes before the visit is covered in the prior authorisation guide, and what comes after in the guide to cutting claim rejections.

Why one invoice for both parties does not work

Some clinics raise one invoice for the whole visit, record the patient's payment against it, and wait for the insurer to pay the rest. That mixes two different debts in one document, and the result shows up in more than one place:

• The patient's balance looks open because the insurer's share is still on their invoice, so they are chased for money they do not owe — and may see it in the patient portal.
• The claim is made on an amount that is not the insurer's, because the invoice includes the patient's share, so the dispute starts on the first line.
• The tax invoice names the wrong buyer when the payer is a VAT-registered business: the buyer is the insurer, not the patient.
• Collection reports mislead, because one invoice holds money that arrived today alongside money that may arrive in sixty days, or never.

The usual answer is two linked invoices: one to the patient for their share, paid at the desk, and one to the payer for the rest, which the claim is made against. Together they add up exactly to the visit, and each refers to the other, so whoever reviews them later knows they are one visit.

Start from the payer's price list, not yours

Insurer and corporate contracts usually set an agreed price for each service, different from your cash price and different from one payer to the next. Bill the insurer at your own price and the difference comes back weeks later as a short payment — without anyone having made a coding or eligibility mistake.

So keep each payer's terms in one place that whoever raises the invoice can see, not in a file on the finance manager's desk:

A worked example: splitting one visit

An insured patient has a consultation at 300 riyals and an X-ray at 200, so 500 before VAT. Their policy's co-payment is 20%, capped at 50 riyals per visit. Twenty per cent of 500 is 100, but the cap brings it down to 50. The patient's share is spread over the two lines in proportion to their value, and the rest goes to the insurer:

Spreading the share over the lines rather than putting it on one line matters for two reasons: each line keeps its own VAT category, and each invoice reads on its own without explanation. The two invoices total 470 before VAT — the visit after the discount, not a riyal more or less. If the clinic is in Saudi Arabia and the patient is a citizen, the VAT on their share is treated differently from the insurer's, as the guide to the citizen's zero-rated healthcare explains.

Discounts on a split visit

The common mistake is to apply the discount to both invoices: a 30-riyal discount on the visit becomes 30 off the insurer's invoice and 30 off the patient's, and the clinic loses 60 without anyone meaning to. The clearer rule is that the discount is entered once, on the visit, and then shared between the two invoices in proportion to their shares, as in the example: 3 riyals off the patient's share and 27 off the insurer's.

• Agree in writing with each payer how a discount is treated: whether the co-payment is worked out before or after it, and whether a discount is allowed at all on a service with an agreed price.
• Do not use a discount to waive the co-payment without the payer knowing; some contracts treat that as a breach.
• Cap discounts by role, because a discount on a split visit touches two parties' money, not one.

Two linked invoices, one claim

The patient's invoice is paid at the desk and closed the same day. The payer's invoice is the one the claim is made against, followed up until it is paid on the agreed terms, counted from the day it was issued. A claim is never made on the patient's invoice, nor on an invoice made out to a payer other than the one being claimed from — a claim that does not match its invoice is rejected before anyone reads it.

In Saudi Arabia, a VAT-registered payer gets a standard tax invoice in its own name, with its VAT number and national address, and under Phase 2 of e-invoicing that invoice is cleared by ZATCA before it is handed over. The details are in the Phase 2 guide for clinics.

When the insurer pays less than the claim

A short payment is not a full rejection, which is why it is so often ignored: the money arrived, the gap is small, and everyone is busy. But small gaps repeated across hundreds of claims make a large number by the end of the year. Deal with them in fixed steps:

What to review every month

• Each insurer's ageing: what it owes up to 30 days, 31 to 60, 61 to 90, and over 90. An insurer whose last column keeps growing needs a phone call, not patience.
• The not-covered list: every payer invoice whose claim was rejected or paid short and still has something on it, so it is credited off or billed to the patient rather than forgotten.
• How often each claim was resubmitted: a claim sent back twice for the same reason points to a broken process, not a broken claim.
• Co-payments collected at the desk: if patients' share invoices stay open after the visit, the problem is at the desk, not with the insurer.

These are part of the KPIs every clinic manager should track, and the terms — co-payment, payer, remittance advice, ageing — are defined in the glossary.

How 3yadtk handles payer billing

In 3yadtk, insurers and companies are set up once under Settings → Clinic, with their VAT number, national address and payment terms, their agreed price for each of the clinic's services, and the patient's co-payment with its cap per visit. An invoice made out to a payer is filled at that payer's prices, and with a co-payment set the visit splits in one step into two linked invoices — the patient's share to them and the rest to the payer — created together or not at all, adding up exactly to the visit, with any discount shared between them in proportion. The payer's bill never shows as the patient's debt or in their portal, and falls due on the payer's terms from the day it is issued. A claim is recorded against the payer's invoice only, then worked from submission to settlement: approved; rejected with the insurer's reason, then corrected and resubmitted with a note of what changed; or paid and booked on the invoice. An insurer's remittance file is imported against its claims, what each insurer owes shows by age, and what an insurer rejected or paid short is listed for someone to act on. In Saudi Arabia a VAT-registered payer gets a standard invoice which, under Phase 2, prints only once ZATCA has cleared it. Claims are tracked and exported as a file; they are not sent to insurers electronically from the system, so submission stays on the insurer's own channel. The details are on the features page.