Managing insurance adjustments

Insurance payers may audit and reprocess claims after they’ve been paid, which can result in insurance adjustments. This guide explains how adjustments appear in SimplePractice, how to review them, and how to ensure your payments and income are reflected accurately.

• Viewing insurance adjustments
• Receiving insurance adjustments
• Reviewing unallocated amounts on adjustment insurance payments
• Reviewing final insurance payment details

Important: Insurance payers provide limited information on Payment Reports regarding the reasons for adjustments. To determine why an adjustment occurred and what steps to take next, contact the payer directly.

Viewing insurance adjustments

There are two ways you can view insurance adjustment payments.

From the claim

1. Navigate to Insurance > Claims
2. Locate the claim in question
3. Click View

4. Click Claim Details

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

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

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

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

From the Insurance Payments page

1. Navigate to Insurance > Payments
2. Locate the payment
   • An adjustment insurance payment is often indicated by an Unallocated amount

3. 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 reflects the funds sent in the Amount field.

The amount processed toward each appointment appears in the Insurance Paid column.

Clawback payment

When updating or retracting a previous payment, an insurance payer sends a clawback to cancel the original payment. A clawback is indicated by ADJ before the Payment Method number.

Note: A clawback may also be referred to as an adjustment, retraction, takeback, or recoupment.

The retracted amount appears as a negative value in the Insurance Paid column.

A clawback Payment Report is indicated by CR beside the retracted amount.

Updated payment

After a clawback, payers typically send an updated payment reflecting the corrected amount. This updated amount appears in the Insurance Paid column and may be lower than, equal to, or higher than the original payment.

Note: Payers often withhold funds from the updated payment, which can result in an Unallocated amount.

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: 

1. Navigate to Insurance > Claims 
2. Locate the claim in question
3. Click View 
4. Click Claim Details

5. 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 

6. Review the Payment overview to determine if the Client responsibility and insurance Write-off amounts are reflecting correctly 

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: 

7. Click Received next to the most recent insurance payment to navigate to the payment 

8. Click Edit 
9. Adjust the Client Owes to the correct amount

10. Click the wheel icon in the Write-off column to automatically calculate the write-off 
11. 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. For more information on write-offs, see Entering insurance write-offs.