If a client’s insurance appointments aren’t settled, they may have an insurance balance or credit. An insurance balance indicates an appointment’s insurance responsibility hasn’t been fully accounted for, and an insurance credit indicates an insurance payment exceeds an appointment’s insurance responsibility. You can resolve these by updating the appointment’s billing details and/or insurance payment.
In this guide, we’ll cover:
- Locating an insurance balance or credit
- Determining the source of an insurance balance or credit
- Reviewing an appointment’s billing
- Reviewing an appointment’s Payment Reports
- Adjusting an appointment’s billing
Locating an insurance balance or credit
If your client’s Billing Type is Insurance, a red Insurance Balance amount on their Overview page indicates that they have an outstanding insurance balance.
A red amount followed by CR indicates that a client has an insurance credit.
Note: Self-Pay clients with insurance appointments may also have insurance balances or credits.
To view the insurance balances or credits for all client insurance appointments, navigate to Analytics > Reports > Unpaid insurance appointments. This report will display all insurance balances and credits in the Ins. Balance column.
To view insurance balances and credits for all clients, navigate to Analytics > Reports > Outstanding balances. For an overview of using this report, see Outstanding balances.
Determining the source of an insurance balance or credit
You can use a client’s Appointment Status report to determine which appointments are contributing to an insurance balance or credit. If your client has an insurance credit that doesn’t appear in the report, it may stem from canceled appointments.
Investigating with the Appointment Status report
To investigate an insurance balance or credit using a client’s Appointment Status report:
- Navigate to the client’s Overview page
- Click Appointment Status Report under Client billing
- Click More and toggle on Include Insurance
- Review the Unpaid column under the Insurance Responsibility section for appointment(s) with an insurance balance or credit (CR)
Note: If you’re not seeing any appointments with an Unpaid amount, you can adjust the date range to begin from the client’s first date of service.
Once you’ve found an appointment with an Unpaid amount, see Reviewing an appointment’s billing for next steps.
Investigating canceled appointments
If a client’s Appointment Status report doesn’t show any appointments with insurance credits, the credit may stem from appointment(s) that’ve been Canceled or Clinician canceled.
Insurance payments can’t be added to canceled appointments. If an insurance payment was added for an appointment before it was canceled, it’ll reflect as an insurance credit.
To identify canceled appointments contributing to an insurance credit:
- Navigate to the client’s Overview page
- Click All Items and select Appointments
- Take note of appointment dates with a Canceled or Clinician canceled status
- Click the Billing tab
- Update the Billable items filter to Transactions by insurance
- Adjust the date range to start before the client’s first appointment
- Click View for an insurance payment dated around the client’s canceled appointment(s)
-
Look for the canceled appointment’s date(s) among the dates of service listed
- If the insurance payment doesn’t include the appointment(s), look through other insurance payments until you find the appointment(s)
If the appointment status should be Show, you can update the appointment’s status through your calendar. This will allow the insurance payment to apply to the appointment, and remove the insurance credit.
If the appointment is actually a Canceled or Clinician canceled appointment, reach out to the payer for next steps to rectify this, such as submitting a corrected claim. If its insurance payment was manually added, edit the insurance payment and remove the Insurance Paid and Write-Off amounts for the appointment.
Reviewing an appointment’s billing
An insurance balance or credit indicates that the total of the client's responsibility, the amount insurance paid, and the insurance write-off don’t equal the appointment’s fee.
You can use the client’s Appointment Status report to review these values for an appointment. The following table indicates the labels for these values in the Appointment Status report:
| Value | Label |
| Client responsibility | Charge under Client Responsibility |
| Insurance responsibility | Charge under Insurance Responsibility |
| Insurance payment amount | Paid under Insurance Responsibility |
| Insurance write-off | Write Off under Insurance Responsibility |
| Appointment fee |
Total Fee |
Note: To view how these values are worded in an insurance payment, see Editing insurance payments.
Based on these labels, you can determine which item(s) need to be corrected so that the combined client responsibility, insurance paid amount, and insurance write-off are equal to the appointment’s fee.
As an example, the screenshot below indicates that the appointment on 09/12/2023 has an insurance credit. This is because the client's responsibility is set as the full fee, but an insurance payment and write off have also been added to the appointment.
The report reflects the following for the appointment:
- Appointment fee: $100
- Client responsibility: $100
- Insurance paid amount: $25
- Insurance write-off: $50
Note: If you have an existing insurance payment that should be applying to an appointment, it’s possible that the appointment’s type is currently Self-Pay, which would cause an associated insurance payment to appear as credit. You can update the Billing Type of the appointment to Insurance to apply the payment.
Reviewing an appointment’s Payment Reports
If you’re enrolled for Payment Reports (ERAs) with a client’s payer, you’ll receive Payment Reports for their claims. If an appointment’s billing is reflecting incorrectly, you can review the appointment’s Payment Reports to determine the correct values.
If a claim is associated with an appointment, you can click Details in the Appointment Status report to access the Claim Details page.
The Claim Details page includes the following information:
| Claim details | Meaning |
| Status | This page shows the status and details of the claim, the Payment overview section, and the Insurance payment report (ERA) section. |
| Payment overview |
This section is an overview of the billing details for the claim. For each appointment, it shows the Billed appointment fee, Client responsibility, Insurance paid amount, and Write-Off. It also links out to any added insurance payments. The Status for an appointment in this section can be:
|
| Insurance payment report (ERA) | This section shows the Payment Reports (ERAs) received from the payer. Each Payment Report lists the information for the corresponding insurance payment. |
| History | This page shows how many times the claim has been submitted, the status of each submission, and any errors that may have occurred. Each unique Clearinghouse Reference # indicates a separate claim submission. |
Under the Insurance payment report (ERA) section, you can view the Payment Report(s) associated with the claim. Generally, you’ll want to make sure that the values here match the insurance payments in the Payment Overview, so that they appear as Settled.
The respective labels for relevant values are listed below:
| Value | Label |
| Client responsibility | Client Responsibility |
| Insurance payment amount | Paid |
| Insurance write-off | Adjustments, typically under Contractual obligation |
| Appointment fee | Billed |
For example, the screenshot below shows that the claim’s insurance payment should reflect the following:
- Appointment fee: $275
- Insurance payment amount: $109.58
- Client responsibility: $9.40
- Insurance write-off: $156.02
Note: If it isn’t possible to determine the correct values from the Payment Report(s), we recommend contacting the payer directly and taking note of the name of the representative, the call reference number, and the phone number called in case we need to reach out to our clearinghouse. For more information on Payment Reports in SimplePractice, see ERAs in SimplePractice (Payment Reports).
If a claim isn’t attached to the appointment, you can navigate to its insurance payment by viewing the appointment details. For more information on this, see Editing insurance payments.
Adjusting an appointment’s billing
If an insurance appointment’s billing is reflecting incorrectly, you can update it by following three common workflows:
Making an appointment level billing change
With this method, you can update an appointment’s Type, Fee, and the client’s responsibility, which is listed as the Client Owes amount. To do this, see Appointment level billing changes.
Editing insurance payments
When you edit an insurance payment, you can adjust the client responsibility, insurance payment amount, and insurance write-off.
If the appointment has a claim, you can navigate to the insurance payment from the Payment Overview section of the Claim Details page. Alternatively, you can navigate to an appointment’s insurance payment through the appointment billing details, under the Insurance payments section.
Once you’ve located the insurance payment, you can make the necessary edits. The relevant values of an insurance payment appear under the following labels:
| Value | Label |
| Client responsibility | Client Owes |
| Insurance payment amount | Insurance Paid |
| Insurance write-off | Write-Off |
| Appointment fee | Billed |
For more information on editing an insurance payment, see Editing or deleting an insurance payment.
Sometimes, appointments may have multiple insurance payments. This is typical for appointments covered by primary and secondary insurance, and appointments with insurance adjustments.
Below is an example of an insurance payment that’s applying to an appointment with multiple insurance payments, listed as Other Payments:
An appointment that has multiple insurance payments with write-offs, or a payment with an incorrect write-off, can cause an insurance balance or credit.
To settle the appointment’s billing, you’ll first want to check that all insurance payments have a $0 write-off, except for the most recent insurance payment. To do this, see Reviewing final insurance payment details.
Adding insurance payments
Insurance balances are mostly caused by missing insurance payments or write-offs. If an insurance payment is missing, you can:
- Manually add an insurance payment to your appointments
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Enroll for Payment Reports with the client’s payer to have insurance payments automatically recorded for future appointments
- If you’re missing Payment Reports, see Investigating missing Payment Reports
If you’re enrolled for Payment Reports, write-offs won’t be automatically calculated for deductible appointments, which will cause an insurance balance. In this situation, you can either:
- Add a $0 insurance payment to reflect this insurance balance as a write-off if the clinician is in-network with insurance, or
- Update the appointment to Self-Pay if the clinician is out-of-network with insurance and the client is responsible for the full fee
To learn more about both workflows, see Billing clients who haven’t met their deductible.