The credit balance is a liability that sits in the account receivable (A/R) folder and is considered important as the liability carries with it serious and real, compliance and financial risks. It is the responsibility of the medical billing service provider, to manage those risks. With the greater emphasis on billing and collections, there are growing volumes of credit balances that accumulate within A/R, and these unresolved credit balances represent a significant source of medical expense recoveries to healthcare Payers, while also in some cases signifying compliance risks and penalties.
It is often recommended, that Providers partner with a vendor to expedite and maximize credit balance refunds. The Healthcare Financial Management Association (HFMA) estimates that a small-to-medium-size Hospital generates approximately $2M in credit balances annually.
According to the Social Security Act, Section 1128J, any funds that a person/agency receives or retains under Title XVIII or XIX to which the person, after applicable reconciliation, is not entitled, constitutes an overpayment. These can include claims for services after benefits have been exhausted, payment for non- medically necessary services, duplicate payments,and payment of claims that exceeded a reasonable charge. These are usually caused by contractual 'over adjustments,' misapplication of payments, and overpayments.
Medical billing industry data shows that 35% plus of the credit balances are caused because of incorrect allowances posting. Federal Register, issued rules on credit balancing in March 2016 and as per the rules:
The Healthcare Financial Management Association (HFMA) says credit balances occur due to 3 major reasons:
55% incorrect posting of allowances
35% duplicate payments and overpayments by patients and payers
While choosing a credit balance vendor, the vendor must be given access to the Provider’s business offices across locations and a collaborative working relationship must be established with the administrative staff. The vendor should be equipped to provide online, on-demand reporting which includes, drill-down capabilities,error code analysis, and Provider trending. The vendor will need to compare results with in-depth root-cause analytics to uncover systemic problems, so they can be resolved and discontinued. The vendor must be capable to assure that all data and communications are secure and compliant with HIPAA regulations.
To develop a solid strategy for resolving over payments and preventing errors, the credit balance team needs to have an in-depth understanding of both internal processes and specific business objectives with the overall flexibility to customize an approach that fits an organization’s specific needs.One of the primary roles of a credit balance vendor is to examine billing data to pinpoint erroneous patterns that lead to overpayments. The most effective way to deal with credit balances is to identify the root cause of errors to prevent them from recurring.
Highlighted below are few pointers which are summarized as best practices:
1. Identify true overpayments
2. Work balances from the oldest to newest
3. Analyze credit balances using :
4. Identify if patient is an eligible medical beneficiary
5. Check if medical payment rules apply
6. Identify Primary payer and other liable insurers
7. Verify that all credit balances are due and refundable
8. Monitor staff compliance with policies/procedures
9. Identify preventable causes of credit balances
10. Seek professional outsourcing assistance, in case existing staff cannot handle credit balance resolutions
RCM is a core component of fiscal responsibility. RCM credit balance review includes the identification and resolution of any credit balances that may have accrued during a billing cycle. A credit balance review is required and regulated by law and helps clean up unnecessary open accounts on the A/R. The RCM process ensures that every payment, credit, and adjustment is checked systematically across the entire A/R spectrum. Review of coding errors,incorrect billing or payment duplication is necessary to identify the source and close it.
Resolving credit balances can prove to be a costly and time-consuming activity. However,automation is the best way to improve workflow and make the best use of human resources. Most organizations may or may not have the automation technology or proper staff to take advantage of such technologies. It is best advised that healthcare organizations should consider engaging with third party specialists to handle it. These vendors will take a comprehensive look at patient records,make the transition to a technology-based credit balance management process and improve the resolution and bring in more efficiencies to healthcare organizations.
Credit balance accounts form part of the reimbursement environment, and resolving these credits is a huge task, and ignoring these credit balances can lead to larger problems. Overpayments going unresolved, sitting on the Provider’s books means Providers have inadequate staff to resolve these issues or challenges. In such scenarios, there is an acute dependency on vendors to process the amounts owed to the Payers.
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