How crucial are certain adjustments while posting payments?

While it is true that payment posting is merely an exercise of recording the actual claim realized against patient account concerned, in reality its scope extends beyond that.  Far from just being an accounting exercise, payment posting has evolved into an indispensable tool for analyzing and augmenting revenue generation from medical claim realization from medical insurance providers. Today, the quality of payment posting exercise can either make or break your final financial report. Therefore, medical practitioners across the healthcare continuum are beginning to lay emphasis on this pivotal component more than ever before. Consequently, the cash posting or payment entry department if yours is an in-house medical billing practice, or your medical billing service provider if yours is an outsourced medical billing practice should view payment posting not merely as posting of the details contained in the explanation of benefits (EOB) from the health insurance providers, but also charging the appropriate patient’s account and initiate the process for denied claims if the actual claim happens to be far below the expected one.

But before your medical billing and coding department or service provider can embark on the process of appealing against delay or denial, it is imperative that they look into certain adjustments that are integral to any medical billing fee reimbursements. This could save you from being embarrassed when you actually come to know that you have compared the explanation of benefits (EOB) from the health insurance providers in isolation of certain out-of-pockets expenses, co-payments, deductible, allowable limit, etc. Therefore, it becomes inevitable that medical practitioners heed to following adjustments before they can actually make qualms against under realized claims:

  • Billed Amount, the amount which the physician charges for his medical services.
  • Allowed Amount, the amount that insurance company agrees to bear for medical  services availed by its beneficiary.
  • Write-off, the difference between the billed amount and the actual amount allowed by the insurance company.
  • Participating/Non-participating, being participatory a physician accepts whatever the insurance company offers as payment for his medical services. Whereas, in non-participatory role he can bill the patient for the difference between the allowable and the billed.
  • Deductible, the amount borne by the beneficiary before his coverage actually gets effective.
  • Co-insurance/co-payment, wherein a primary insurance company shares a part of the payment with the secondary insurance company.
  • Balance bill, where in a non-participating primary insurance company pays a part of a claim, allowing the balance on the claim to be billed to the patient or secondary insurance company.
  • Out-of-pocket expenses, wherein patient himself meets certain medical-related expenditure – deductible, co-pay, co-insurance and balance bills happen to be “out of pocket expenses”.
  • Contract Maximum, wherein  insurance companies earmark the maximum payable amount on certain illness or policies.
  • Offset, wherein insurance company recovers previously allowed excess EOB  from subsequent payments.

When one considers these incidental factors that have a direct impact on the quality of payment posting, which in turn has a direct bearing on the financial reporting, it is obvious that physicians would do well with tried and tested payment posting practices. (, whose payment posting practices are part of its credible medical billing Revenue Cycle Management (RCM) services, should amicably address inherent challenges in payment posting.

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