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Managing insurance adjustments

Managing insurance adjustments

Insurance payers often audit claims that they’ve previously processed. When reprocessing a claim, they’ll send adjustments to update the initial payment. Insurance adjustments will be automatically recorded in SimplePractice if you’re enrolled to receive electronic Payment Reports. If you’re not enrolled, you can manually add them to accurately track your income.

In this guide, we’ll cover: 

Important: Insurance payers provide limited information on Payment Reports regarding reasons for adjustments. To determine the reason for an insurance adjustment, as well as next steps, contact the payer directly. 


Viewing insurance adjustments

There are two ways you can view insurance adjustment payments. 

Through the claim  

  • Navigate to Insurance > Claims 
  • Locate the claim in question
  • Click View 

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  • Click Claim Details 

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Note: For an overview of what’s included in the Claim Details page, see Reviewing the Claim Details page

Review the insurance payments attached to the claim in the Payment overview.  

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Scroll down to the Insurance payment report (ERA) section to review the full Payment Report for each payment. 

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Note: You can review all Payment Reports under Analytics > Reports > Payment Reports. For more information, see Viewing a Payment Report

Through the Insurance Payments page 

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  • Click View 

Receiving insurance adjustments 

In this section, we’ll cover the different stages an insurance adjustment goes through. 

Important: Insurance payers provide limited information on Payment Reports regarding reasons for adjustments. To determine the reason for an adjustment, contact the payer directly. 

Initial payment 

When an insurance payer first processes a claim, the insurance payment will reflect the funds sent for the payment in the Amount field. 

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The amount processed towards each appointment will reflect in the Insurance Paid column. 

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Clawback payment

When updating or taking back a previous payment, an insurance payer will send a clawback to cancel their initial payment. A clawback is indicated by an ADJ before the Payment Method number.  

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Note: A clawback is a standard insurance process and can also be referred to as an adjustment, retraction, takeback, or recoupment. 

The amount that the payer rectracted for each appointment will reflect in the Insurance Paid column as a negative number.   

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Note: When retracting a previous payment, insurance payers usually don’t take back the funds that were previously paid, causing an Unallocated amount. For more information, see Reviewing unallocated amounts on adjustment insurance payments

A clawback Payment Report is indicated by CR beside the amount that was taken back.  

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Updated payment 

After retracting their initial payment, insurance payers will typically send an updated payment reflecting the new amount processed towards an appointment. The updated amount will reflect in the Insurance Paid column and can be lower than, equal to, or higher than the original payment.  

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Note: Payers will generally withhold the funds that they sent for the initial payment from the updated payment, which causes an Unallocated amount. For more details, see Reviewing unallocated amounts on adjustment insurance payments

Payers will often send a retraction and an updated payment together. In this situation, both payments will have the same Payment reference number.  

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Reviewing unallocated amounts on adjustment insurance payments 

The Amount field of an insurance payment should reflect the transfer of funds between yourself and the insurance payer. The Insurance Paid column should reflect the amount that was processed for each appointment on the payment. 

The Unallocated field on an insurance payment reflects the difference between the Amount field and the sum of the amounts in the Insurance Paid column. Because insurance payers redistribute funds when making adjustments, unallocated amounts are expected on adjustment payments. 

Note: For information on other scenarios that can cause unallocated amounts, see How to resolve unallocated insurance payment amounts

Unallocated amounts on clawback payments

When a payer retracts a payment, they’ll normally withhold the funds from an updated payment or from a future payment. Because of this, the Amount field on a clawback payment should be set to $0, causing an Unallocated amount. 

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When a clawback payment is automatically generated, the Amount field may be incorrect. If this is the case, it should be updated for proper accounting. To do this: 

  • Navigate to Insurance > Payments 
  • Locate the clawback payment 

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  • Click View 
  • Click Edit at the top of the screen
  • Adjust the Amount to $0 

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  • Click Save Payment 

If you refunded the funds to the payer outside of SimplePractice for the clawback, you can instead enter the refund as a negative number in the Amount field. 

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Negative unallocated amounts

When an insurance payer withholds the funds for a clawback from another payment, the withheld funds will reflect as a negative Unallocated amount. This is often referred to as an Overpayment Recovery or a Forwarding Balance. 

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If the payer doesn’t owe you any funds for a payment, the Amount will be $0, and NON will display alongside the Payment Method number. 

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If funds were withheld from a payment and there isn’t a clawback payment with the same Payment reference number, you can download the Explanation of Benefits (EOB) to determine if the funds were withheld because of a previous adjustment. To do this: 

  • Navigate Insurance > Payments 
  • Locate the insurance payment 
  • Click View
  • Click Download EOB 

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An Overpayment Recovery or Forwarding Balance indicates that the payer withheld funds from the payment because of a previous retraction. 

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Unallocated amounts on the Insurance Payments page 

On your Insurance > Payments page, the Unallocated column should typically reflect the retracted funds for a clawback payment. When a payer withholds retracted funds from another payment, the Unallocated column should reflect the withheld funds.

Note: If a clawback and updated payment are sent together, they’ll have the same Payment reference number. 

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Important: Insurance payers provide limited information on Payment Reports regarding reasons for adjustments. If you need to determine why funds were withheld from a payment, contact the payer directly. 


Reviewing final insurance payment details 

If an insurance payer sends multiple adjustments or Payment Reports out of order, the final payment details may reflect incorrectly. To review the final payment details for a claim: 

  • Navigate to Insurance > Claims 
  • Locate the claim in question
  • Click View 
  • Click Claim Details

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  • Review the Insurance payment report (ERA) history to determine which Payment Report is reflecting the final payment details 
    • If you can’t determine which Payment Report is reflecting the final payment details, contact the payer directly to confirm 

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  • Review the Payment overview to determine if the Client responsibility and insurance Write-Off amounts are reflecting correctly 

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Note: If a Payment Report is missing, see Investigating missing Payment Reports

If the Client responsibility or insurance Write-Off are reflecting incorrectly, you can update the most recent insurance payment to reflect the correct amounts. To do this: 

  • Click Received next to the most recent insurance payment to navigate to the payment 

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  • Click Edit 
  • Adjust the Client Owes to the correct amount

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  • Click the wheel icon in the Write-Off column to automatically calculate the write-off 
  • Click Save Payment 

Note: The write-off for an appointment should be entered on the last insurance payment received. If there are write-offs on multiple insurance payments for a claim, you can follow the steps above to adjust past write-offs to $0, and update the write-off on the last insurance payment. 


FAQs 


Why did I receive an insurance adjustment? 

There are many potential reasons for insurance adjustments, such as changes to a client’s plan or a client reaching their deductible. Insurance payers provide limited information on Payment Reports regarding the reasons for insurance adjustments. To determine why an adjustment was made, we recommend that you reach out directly to the payer. 


Should I resubmit a claim after an insurance adjustment?

If an insurance payer retracted a payment without sending an updated payment, they might require that you complete additional steps or submit a corrected claim. We recommend that you reach out directly to the payer for guidance on next steps. If they request that you submit a corrected claim, see When to submit a corrected claim in SimplePractice and how


How do I record insurance adjustments if I’m not enrolled for Payment Reports?

If you’re not enrolled for Payment Reports with an insurance payer, you can manually enter insurance adjustments. For a walkthrough of these steps, see Adding insurance payments.

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For an overview of how adjustments should reflect, see Receiving insurance adjustments


How do insurance adjustments affect my income in SimplePractice? 

The number in the Amount field of an insurance payment directly corresponds with your income. This field should always reflect the transfer of funds between you and the payer outside of SimplePractice. If the field doesn’t accurately correspond with the transfer of funds, your income and income reports in SimplePractice won’t reflect correctly. 

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The Amount field may populate incorrectly on adjustment insurance payments. For more information on how this field should reflect on adjustment insurance payments, see Reviewing unallocated amounts on adjustment insurance payments

For more information on your income reporting, see Understanding your income reports


How do I know I received an insurance adjustment? 

Insurance payers often adjust their previous payments. You may have received an insurance adjustment in the following scenarios. We recommend that you regularly review your Insurance > Payments page to determine if an insurance adjustment has been received and to confirm that all your payments are reflecting correctly.

The client responsibility and/or insurance responsibility were automatically updated for an appointment that was previously processed 

  • If you notice the client responsibility or insurance responsibility has been adjusted for an appointment that was previously processed, you can review the Payment Reports for the claim to determine if an insurance adjustment was received. For more information, see Receiving insurance adjustments

You received a practice reminder for an unallocated insurance payment, a Payment Report adjusting a client responsibility, or a new insurance payment for an appointment that was previously processed 

  • Insurance adjustments will often involve one of these scenarios. For each situation, you’ll receive a practice reminder in the Reminders tab on your Calendar homepage. You can click on the link in the reminder to review and determine if there was an insurance adjustment. For more information, see Using practice reminders

A claim has multiple Payment Reports 

  • If you’re enrolled for Payment Reports, each insurance adjustment will have a corresponding Payment Report. You can review the Payment Reports for an individual claim by navigating to the claim and clicking Claim Details. For more information, see Receiving insurance adjustments.  

An insurance payment has an Unallocated amount 

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