Out-of-Balance Collections and Claims

Occasionally, users may encounter payments, collections, or even claims that are out of balance, often due to errors with payment posting. The RCM offers several features intended to help organizations identify and resolve out-of-balance items in the Work Center - let's review these together and learn how to resolve them!

User Permissions

Users with admin-level permissions can access and edit this information. For user-level profiles, additional permissions must be configured by an admin before access can be granted. For more information on user profiles and permissions, click here.

Payment Definitions

Understanding how to read an EOB is crucial to ensuring payments are posted accurately and resolving any unbalanced payments. Let's review some of the fields users may encounter when reviewing payments.

Out-of-Balance Payment Collections

The RCM provides organizations with a designated section in the Work Center to review and resolve Payment Collections with one or more unresolved issues. Click below to learn more about the most common reasons a payment collection may need review.

If the sum of all payments applied within a collection does not equal the check amount, the system will flag the collection for review with this status. To resolve this issue, click View EOBs to confirm which payment is missing, then click Edit to Resolve to be redirected to the Payments tab. Follow the process outlined here to create and apply the payment.
Collections that were created but have no payments applied will be flagged for review under this status. Follow the process outlined here to create and apply the payments.
If a payment collection already exists using the same check number, the system will flag the newer collection as a duplicate for review. Confirm whether the check already exists in the RCM by searching the check number, then click Resolve Duplicate.

Out-of-Balance Claims

Claims in which the patient's responsibility exceeds the charges or the balance is negative will be flagged for review in the Work Center.

Negative Balance Claims

Claims with a negative balance indicate that the system believes there was an overpayment. Click through each scenario below to determine the right solution for you.

Occasionally, payers may issue a payment at a higher-than-expected rate. When this occurs, you may notice that the overall balance of the claim is $0.00, but the Balance (Difference Covered vs Expected) will be displayed as negative.

To resolve this issue, use the following steps:
1. Open the Payments tab and click View EOBs to confirm that the entered payment totals match the EOB totals.
2. If all fields are entered correctly, have an admin confirm that the entered expected rate is accurate to the contract. If it is incorrect, reference this article for information on managing expected rates.
3. If both the payment and expected rates were entered correctly, click Ignore to remove the claim from the Work Center.
Some payers will adjust a payment, regardless of how many times a claim was submitted. When this occurs, the system applies each payment to the claim and flags it for review. In these cases, the system cannot determine which payment is the correct payment and requires manual intervention to ensure only the correct payment is applied. Failure to rectify out-of-balance claims leads to a loss of data integrity.

In this example, we see that the claim has two payments applied to it, both for $2,150, totaling $4,300.

The first payment posted was posted correctly and uses adjustment codes to reduce the remaining balance to $0, leaving the claim balanced.

The second payment posted incorrectly indicates that a second $2,150 payment was received and that no adjustment codes are present. As a result, the system believes the claim was overpaid, resulting in a negative balance and flagging it for review.

To resolve this, view the EOB of each payment to confirm its accuracy, then click Apply Reversal.

Applying a reversal will still leave records of the second payment and the reversal, but will instruct the system not to apply it to the claim, so the correct payment is reflected in the balance. Note that reversals can be unapplied/reapplied at any time.

Patient Responsibility Greater Than Charges

The RCM determines the patient's balance by using the following formula: Deductible + Co-Pay + Co-Ins. + Adjustment Codes (PR + OA100+) = Patient Responsibility. If a posted payment indicates the patient's responsibility exceeds the formula sum, the balance will be negative, and the system will flag the claim as out of balance.

In this example, we can see the billed amount is $100.00, the Co-Ins. is $35.00, and the provider was paid $46.74. If the payment was posted correctly, the adjusted amount would have been $18.26

However, the payment adjustments were incorrectly posted as a PR-45, leading the system to believe the patient's responsibility is $418.26, resulting in a $400 overpayment.

Helpful Hints

Click below to see commonly asked questions and how to resolve them!

Organization Admins and Managing Organization Admins should utilize the Organization Dashboard within the Management Center. The RCM does not have a dedicated area for out-of-balance individual payments; instead, the system flags these payments, reassigns them to a specified queue, and updates the tiles in the Organization Dashboard related to payment posting.

Once flagged, the system will sort these payments into one (or both) categories that can be found by navigating to the Work Center > Insurance Payments section.
Inaccurate payment posting should always be resolved to ensure the data integrity of an organization's reports. For example....
For organizations with the Patient Billing module, errors in payment posting may artificially inflate the patient's balance and result in a billable being approved and sent to the patient for payment.

If you find that a billable was approved with the incorrect patient responsibility, use the steps below to resolve the issue.
1. In the Work Claim screen, locate the Payments tab and click the check number for the payment to be adjusted.
2. Next, click Reopen Claim Instance to reopen the claim.
3. Then click Edit Payment.
4. Enter the correct patient responsibility and click Save.
5. Click Close Claim Instance.
6. Finally, click Close again to confirm and complete the process.