Auto-Close Claims

This feature is currently in limited release to a select group of clients and will be rolling out to everyone in the coming months.

Our latest feature automatically closes claims based on payment received, reducing manual effort. It processes claims for payments posted electronically or manually that meet the set criteria and closes them automatically. For patient billing, it also generates a patient billable for approval once the claim is closed. Let's review this setting together!

User Permissions

Only Managing Organization Admins and Organization Admins can access and configure this information. For more information on user profiles and permissions, click here.

Auto-Close Overview

The auto-close rules are managed in the Organization Admin section in the RCM. These rules establish a criterion that each claim and any posted payment must meet before a claim is automatically closed. It's important to note that these rules will apply only to claims for which payments were posted after the rules were created. When setting up a new auto-close rule, the system offers three options for deciding whether to auto-close the claim: overpayment, underpayment, or correct payment.

Configuration

To create a rule for overpayments or underpayments, you must specify a calculation method—either a percentage or a flat dollar amount—and the amount to be monitored. These figures establish a threshold that the system uses to decide if the claim should be closed.

1. Navigate to the Organization Admin > Configuration > Claim Auto Close section of the RCM.
   
2. Click Configure Auto-Close.
   
3. Next, select the desired payer(s) from the Payers drop-down.
   
4. Toggle on the following settings as desired:
   1. Claim Overpayment Variance Auto-Close: Choose this setting to create an auto-close limit for claims that have been overpaid.
   2. Claim Underpayment Variance Auto-Close: Choose this setting to create an auto-close limit for claims that have been underpaid.
   3. Claim Correct Payment Auto-Close: Select this setting to auto-close all claims with a $0 balance.
      
5. When applicable, update the Variance Calculation Type field to Amount or Percentage.
6. Then enter the desired flat-rate dollar amount or variable percentage, depending on the selected calculation type.
   
7. Once you are done, click Create Auto-Close Rule to complete the process.
   

How Does The System Know When To Close The Claim?

The system will first determine whether the payments were made correctly by referencing the expected rate for the service and payer. If no expected rate exists, the system will use the facility (charge) rate to determine the target rate and compare the claim's overall variance to that rate.

Next, the system will compare the targeted rate to the payment received.

• If the payment matches the rate 100%, meaning there is a $0 balance, the claim will auto-close.
• If the variance from the payment is a percentage or dollar amount over the target rate, resulting in a negative balance relative to the expected amount, the system will compare it against the overpayment type and amount to determine whether the claim should be closed automatically.
• If the variance from the payment is a percentage or dollar amount under the target rate, resulting in a balance relative to the expected amount, the system will compare it against the underpayment type and amount to determine whether the claim should be closed automatically.

• Let's say the payer is Aetna and the claim has an expected rate of $1,000, but the payment received is $900. The rule would need to be set up with an underpayment amount of $100 or 10% to trigger the auto-close feature

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  In this example, let's use Cigna as our payer. The Cigna rule allows claims to auto-close when a payment received has an overpayment of no more than 10%. This means that if the expected rate is $500 and the payment received was $550, the claim would close automatically. However, if the payment was $560, the claim would not automatically close because it was 2% over the allotted variance established by the rule (12%).

Frequently Asked Questions

Click below to learn more about the Auto-Close feature!

• There are three main points of data the system will use to determine whether a claim with a posted payment will be closed:
  • The Home Plan and Primary Payer
  • The Targeted Rate (Expected Rate or Facility Rate)
  • The Variance after comparing the difference of what was allowed vs what was expected (via the expected rate or facility charge)
• A Claim Note will be created when a claim is automatically closed, indicating that the rule was applied.
• Currently, the Auto-Close feature is limited to claims with a single payer and home plan payers.
• Rules can have multiple payers, but no payer can have more than 1 auto-close rule.
• If another payment is received, the claim will reopen and then cycle back to determine whether it should auto-close again.
• Currently, the Auto-Close feature derives its targeted rate from the expected rate. If no expected rate is set, the system will default to the facility charge rate.