Automatic Payment Posting

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The RCM makes managing the revenue cycle a breeze with automatic payment posting. Let's review this process together!

Enrollments

When a new payer is added to your configuration, an enrollment request is generated and added to your organization's Smartsheet. The most common enrollment type is for ERAs and is required by all payers that offer them. This enrollment creates a connection between the payer and the RCM, using the clearinghouse as a conduit, and instructs them where to send the remit to allow for payment posting. For more information on enrollments, click here.

How Does It Work?

When a claim is submitted to the clearinghouse, the RCM sends an outgoing EDI file, known as an 837 file, containing all the information necessary to create the claim. When the payer adjudicates the claim, it sends an incoming EDI file, known as a 835 file, to the RCM containing the information needed to post the insurance payment. 

When the ERA is received, the system compares the contents of the 837 file (ERA) with the contents of the 835 file (Claim) to determine which claim the payment should be applied to. If the system matches all data points, the payment is automatically posted and moved to the Payments in Review queue, with a new follow-up date set for the next business day.

What Are The Data Points Used?

The system will consider 9 data points when making this determination. The first four points will come from the Insurance Billing section of the Practice Admin. The remaining five are determined by the patient's demographic and claim information. If any of these data points do not match, the system cannot automatically post the payment and will require manual matching.

Reviewing Matched Payments

The RCM provides users with several options to review payments. To ensure the accuracy of each payment, we highly recommend viewing each payment before closing the claim.

  • Insurance Payments can be reviewed in the Work Center by navigating to Insurance Payments > Enter Insurance Payment Collections. When a payer sends an ERA, a collection will be created to represent the check issued and allocate payments accordingly. 

    This section of the RCM allows users to view payments by clicking a check number to open the collection.

    Once the collection is open, click on the Payments tab or the View EOBS button to review the payments associated with the collection (check).

  • Another way to review insurance payments is to navigate to the Record Center > Insurance Payments > Payments.
  • Applied payments can be viewed by clicking the Payments tab, then the View EOB button, within the Work Claim screen.
  • Insurance payments can be viewed at the patient level by navigating to Patient > Treatment Episode > Insurance Billing > Payments in the patient's profile and clicking the View option under EOBs.

Manually Match Payments

When the system cannot automatically match and apply payments, manual intervention is required to ensure payments are applied to the correct claims. The RCM will route these payments to the Work Center > Insurance Payments > Review Insurance Payments section. Each payment will list the review reason and determine the next course of action needed to resolve the issue.

Why Is Matching Insurance Payments Important?

Matching payments helps facilities realize revenue by linking pending payments, even non-payments, to claims. Unmapped ERAs leave the follow-up team without current payer info. Mapping payments saves time on follow-up, often eliminating calls, since reviewing a claim is quicker than following up on payments or denials. Additionally, unmatched payments can compromise the integrity of your data by underreporting the payments you actually received.

Review Reasons and Resolutions

Click below for more information about what each review reason means and how to resolve it.

  • This means a $0 or negative payment was received, indicating a recoup was issued or a duplicate claim was submitted. 

    Resolution: View the EOB to confirm its accuracy, then click Resolve to match the payment.

  • This often occurs when the payer sends an ERA in which the patient's name does not match how it was listed in the claim/system. For example, the patient's name is listed as Sheri-Lynn MacArthur in the claim/RCM, but the remit lists it as Sheri Lyn MacArthur.  

    Resolution:

    1. Click View EOBs and verify the patient's name.
    2. Then click Resolve to open the payment.
    3. Next, select the patient's name from the Patient dropdown.
    4. Finally, select the claim instance where the payment should be applied, then click Save to complete the process.
       

  • This means the claim was submitted to one payer ID, but the remit was issued by another payer ID.
    For example, claims submitted to BCBS IN/OH/KY will be remitted by Anthem BCBS.

    Resolution:

    1. Click View EOBs.
    2. Locate the payer name in the upper-left corner of the remit.
    3. Then click Resolve to open the payment.
    4. Next, update the Insurance Payer dropdown to match the patient's insurance.
    5. And select the patient's name from the Patient dropdown.
    6. Finally, select the claim from the Claim Instance dropdown and click Save to complete the process.
        

  • This means the payment line items do not match the claim line items. This is commonly seen with rolled-up payments and recoups. 

    Resolution: View the EOB to confirm its accuracy, then click Resolve to match the payment.

  • This occurs when the claim information in the remit matches a voided claim.

    Resolution:

    1. Click View EOBs and confirm the dates of service.
    2. Then click Resolve to open the payment.
    3. Update the Claim Instance dropdown to the replacement claim and click Save to complete the process.

       

  • This occurs when a remittance is received for a claim submitted outside the RCM. 

    Resolution: Click Mark as Legacy to acknowledge the payment and remove it from the Work Center. A record of the payment will still live in the Record Center for reference.

  • This occurs when one or more EOBs cannot be matched due to the contents of the EDI file.

    Resolution:

    1. Click Resolve.
    2. Next, click the hyperlink for each unmatched EOB to view each one.
    3. When you have located the correct EOB, click the radial button next to it.
    4. Finally, click Save to complete the payment matching process.

  • This occurs when the payer sends a remit without their payer ID included in the EDI.

    Resolution:

    1. Click View EOBs.
    2. Locate the payer name in the upper-left corner of the remit.
    3. Then click Resolve to open the payment.
    4. Next, update the Insurance Payer dropdown to match the patient's insurance.
    5. And select the patient's name from the Patient dropdown.
    6. Finally, select the correct claim number from the Claim Instance dropdown and click Save to complete the process.
       

     

  • This occurs when the system is unable to confidently map each line item of the claim to each date of service listed in the remit due to the data in the EDI. 

    Resolution:

    1. Click View EOBs and confirm the service associated with each line item.
    2. Then click Resolve to open the payment.
    3. Next, update the Service dropdown for each line item to its corresponding line in the remit.
    4. Finally, click Save to complete the process.

Manage Automatically Posted Payments

Insurance payments are managed using the same process, regardless of how they were initially posted. For more information on managing posted insurance payments, click here.

Helpful Hints

Click below to view resolutions to some of the most frequently asked questions about this process.

  • The system will check for EOBs in the clearinghouse (Waystar) four times a day during normal business days at 7 am, 11 am, 3 pm, and 7 pm PST. When a new EOB is received, the system will follow the payment-matching process outlined above and will await review until the claim has been closed.

  • Each payer has its own workflows and a designated clearinghouse to process remits. As a result, some payers may issue payments before the remit, or EOB, is received, in part because our clearinghouse relies on payers' clearinghouses to send these documents. 

    When this occurs, it is not uncommon for the remit to take up to five business days to be ported into the system. In a small number of cases, the remit may not reach the system at all. In these instances, our support team will open a ticket with Waystar on your behalf to locate the missing remit, provided the following requirements are met: 

    • Five business days have passed since the check date.
    • The following required information has been provided:
      • Payer Name
      • Check Number
      • Check Amount
      • Check Date
    • If Waystar is unable to locate the payment with the information provided, please be prepared to include:
      • NPI (Note: multiple NPIs will need multiple cases)
      • Associated Tax IDs
      • Legacy Provider Number or PTAN
      • Provider Number (For State Payers)

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