Outlier payments provide additional reimbursement when costs significantly exceed the bundled payment amount, protecting providers from excessive financial risk. Outlier thresholds define how far costs must exceed the bundle before additional payment triggers, typically 2-3 times the bundled amount. When costs surpass this threshold, providers receive a percentage of costs above the threshold. Outlier provisions […]
Managing patient collections requires balancing financial needs with patient relationships. Options include offering payment plans with manageable monthly installments, providing financial assistance programs for qualifying patients, negotiating reduced lump-sum settlements, or referring accounts to collection agencies as a last resort. Clear communication about financial responsibility before services, transparency about costs, and compassionate but persistent follow-up […]
Coordination of benefits (COB) determines which insurance pays first (primary) and which pays second (secondary). The birthday rule typically determines order for dependent children, with the parent whose birthday falls earlier in the calendar year being primary. For spouses, each person’s own insurance is usually primary for themselves. Claims must be submitted to the primary […]
EOBs provide detailed information about how a claim was processed, including allowed amounts, patient responsibility, denial reasons, and adjustment codes. Reviewing EOBs carefully helps identify underpayments, incorrect patient balances, and patterns in denials. EOBs contain important information for patient billing, showing what insurance paid and what the patient owes. They also provide appeal rights information […]
The appeals process typically has multiple levels. First-level appeals are often informal reviews where you submit additional documentation or clarification to the payer. If denied again, second-level appeals may involve peer-to-peer review with a medical director. Third-level appeals might go to an external review organization. Each level has specific deadlines, usually 30-180 days depending on […]
