While credit balances are unavoidable, identified overpayments should be retained for as short a time as possible. Risks associated with unresolved credit balances include: Medicare/Medicaid penalties, class action litigation, misstated revenues, lost payment opportunities and wasted time and resources.
There are several common causes of credit balances: insurer overpayments or duplicate payments, coordination of benefit conflicts, incorrect payment rates in billing systems, insurer refusal to accept provider-identified overpayment, incorrect upfront collections (coinsurance/deductibles), charge corrections, unintentional, erroneous over billing, and uncashed refund checks.
To assist facilities with dealing with credit balances, the Office of Inspector General (OIG) has made general recommendations in its compliance Program Guidance for Third Party Billing Companies:
• Ensure information systems have the ability to print out the individual patient accounts that reflect a credit balance in order to permit simplified tracking of credit balances.
• Maintain a complete audit trail of all credit balances.
• Designate at least one person as having the responsibility for the tracking, recording, and reporting of credit balances.
• Assign a controller or reasonable equivalent thereof to review reports of credit balances and adjustments on a monthly basis as an additional safeguard.
Not all credit balance accounts are the result of overpayments. In fact, on average, 65% are the result of mis-posted contractual allowances or misapplied payments.
Many facilities often prioritize working unresolved credit balances based on dollar value, working their high dollar credits first. In many cases, due to the volume of new credits created each month, the volume of accounts requiring a review increases over time creating a significant backlog. Often this backlog turns into a “special project” and taxes already stressed internal resources.
In today’s environment, on average, patient accounting staff can resolve only two to four credit balance accounts per hour, which includes the completion of necessary hospital paperwork and document gathering. Hospitals are forced to dedicate significant staffing to work credit balances and avoid the risk of having them spiral out of control.
One solution to this challenge is to outsource this important work to a professional company that has expertise in credit balance resolutions. This solution requires no capital outlay, minimal/no hospital information systems department involvement, and there is no need to install any special hardware or software.
These companies will provide the highest levels of security, with a SAS 70 Type II internal-controls audit, and HIPAA compliance. By engaging a professional outsource company to take charge of your credit balances, they can expeditiously decipher, process and post refunds and/or account corrections to consistently ensure the overall integrity of your revenue cycle, and just as importantly, help you avoid the penalties associated with non-compliance.
What you don’t know about unresolved credit balance can hurt you.