#176 The Insurance Payment Posting Mistakes Draining Your Revenue (Part 2 of 4)

Your AR report says hundreds of thousands of dollars are coming in. But if your team is making these four insurance posting mistakes, a significant portion of that AR is phantom money that was never going to be collected. 

In this episode (Part 2 of our Payment Posting series) we walk through the four insurance-side mistakes that inflate AR and drain revenue: 

• Ignoring contractual adjustments — the gap between billed and allowed sits in AR as uncollectible phantom money 
• Accepting underpayments as paid in full — payer shorts you on a contracted rate, poster writes off the difference without flagging it 
• Leaving zero-balance claims open — fully paid claims clogging your AR and inflating your workload 
• Duplicate posting — same ERA payment posted twice, creating phantom credits and balance chaos 

Each mistake has a fix you can implement this week. 

📋 Free Payment Posting Audit Checklist — the same framework we use in real practice audits: https://eligibility.natrevmd.com/payment-posting-checklist

Resource 1: Payment Posting Audit Checklist — https://eligibility.natrevmd.com/payment-posting-checklist

Resource 2: Book a revenue review — https://calendly.com/heather-natrevmd/

Resource 3: All episodes — natrevmd.com/podcast 

Resource 4: Subscribe on YouTube — youtube.com/@NatRevMD

Transcript

SPEAKER_00 0:04

So a lot of practices think they have an AR problem, but what they really have is an insurance payment posting problem. On paper, your AR could show hundreds of thousands of dollars in outstanding money, but in reality, a large portion of that may be money that's already been deposited into your checking account. Welcome to NatrevMD, a podcast where we share tips on optimizing medical billing and improving practice efficiency so you can have the business of your dreams. I'm your host, Dr. Heather Signorelli, founder of Nat RevMD. Let's get started. So the last episode we said your airport is lying to you. So today we're actually going to name some of those posting mistakes that can cause this issue. And I think this is really important for you guys to understand because oftentimes we're getting asked to manage old AR. And there's this expectation that I've got a million dollars in old AR and I'm going to be able to collect on that. And even though if you understand that that a million dollars in AR is not true, dollars in your pocket, right? Because those are charges, there's this thought that, oh, well, I'll be able to collect, you know, a third of that based on, you know, how you set your fee schedule. But today we're going to talk about, you know, the four insurance payment posting mistakes that can inflate your AR, hide, that can hide underpayments, waste your team's time chasing money, or that you're paying somebody to go and fix when in reality they're never going to be able to fix it. And this is such a hard topic because you can't truly understand what's going on with the AR until you get in there. And so it's really important, even if you are considering changing billing companies down the road, or you think your current billing company is not doing a good job with this, I think if you can really understand these concepts, it will at least give you one things to look out for in your own practice, but also things for you to think about and have some realistic expectations if you are moving companies around collection, right? So what you can actually collect. Obviously, you know that if your billing data is wrong upstream, you know, dashboards, KPIs, even cash forecasting is going to be wrong. And so we've definitely seen owners make major decisions, whether that's hiring or expansion or even compensation changes, with this hope around AR reports that are, you know, with the idea that you're going to be able to collect on all this money. And so, really, really important to understand how these can be inflated at times, especially if somebody is rushing through depositing or uh posting these information. All right, so we're gonna walk through the four most common insurance posting mistakes that we see when we're doing audits or meeting with practices that are looking to come over to us. So for each one of these, I'm gonna explain why it happens, exactly how to fix it, so you can uh work with your team. All right, so number one, ignoring contractual adjustments. So obviously what's happening here is that your post, your payment poster may record the cash as received from the payer, but never actually post the contractual adjustment. So obviously, if you have charges and you have a payment, but then you didn't do a write-off, that then that can cause an inflation of the AR. And the difference, obviously, between your build charges and the contractual allowed amount is going to be the gap that just sits there in the AR. And so that obviously is not going to be collectible. It's phantom money. And so, really, really important for you to make sure that from a payment posting perspective, that they are getting the contractual adjustments correct. For most times, if you've got ERAs connected, so the clearinghouse is set up to bring in the ERAs, right? This is going to work well. Where I see things happening not so well is on the paper EOB side of things. So if you can't get an ERA or you don't have an ERA set up to get those electronically, and you have paper EOBs coming in, this is where we see a lot of issues come in. So that can happen from EDI enrollments never being done, or maybe the payer just doesn't offer that. And so the payment poster may be in a rush to make the deposit, but then they're really skipping the work around the contractual adjustments or really understanding all of the different lines within the paper EOB and making sure that those are posted correctly. Again, for most automated posting, right? So if you have automated posting, which hopefully you do, if you don't, definitely prioritize that. This does get a little bit easier to do. But again, you do want to make sure that those are done correctly and are set up correctly in the system because you can have different rules for how money flows once the payment is deposited and how those contractual adjustments are done automatically, or if that balance is uh flipping to patient and just making sure that that's done correctly. So, a pretty good way to evaluate this is again, you know, picking 10 claims, looking at how the payments were posted, do a mix of those that were posted automatically versus those that are posted through paper EOBs so that you can double check this. Another way, obviously, is looking at, you know, your AR reports and then doing a deep dive into those claims and why they're why they're still sitting there and really understanding, okay, are these just not being touched, right? So AR over 120 days, are they not being touched? Was it just not posted correctly? What was going on? All right, so mistake number two is really around secondaries. And for a lot of secondaries, it's common to have issues with ERAs not coming in to the practice management software. So you're tracking down secondary payment EOBs, and you may not have access to a portal or to Zealous, PaySpan, or any of those. And so a payer may have already paid you the secondary balance. And again, that could be $25, $30, a really low amount. So what happens is the money's hit your deposit, they've hit your checking account, it's been deposited, but then there isn't an EOB to post the payment. And so those secondary balances just sit there. And over time, especially year after year after year, these can actually increase in terms of AR to actually could be a considerable amount of money. And so oftentimes, you know, when your AR team is working AR, they're working from the highest dollar to the lowest dollar. And so some of these like five, 10, $20 claims just sit there. But at the end of the day, you may have already collected the money, but it's just not been posted because you can't find the EOB. And so, really, really important to have a bank reconciliation process so that you can identify, you know, deposits that are coming in. Do you have an EOB? If you don't have an EOB, where is it? So we have a tracking system that we put into place that tracks all of this so that you never lose track of the missing EOB, or if it's the other way around, missing deposit when we have an EOB. And so all of this kind of goes back to reconciliation being a really big part. But so how this impacts your AR, obviously, is you're going to see AR creep up, up, up, and it not be new money that you're going to collect. So if you're paying a team to come in and clean up your old AR, you're paying them to go find EOBs for money you've already received. I've always been baffled by this because most insurance companies get paid on a percentage. So you would think that they wouldn't want to go find the money so that they can also get paid for the work that they've done. Granted, it can be troublesome and again comes back down to accountability, right? So if you don't have a tracking system, who and even if there's an email that's been sent, say, hey, I'm missing the COB, if they don't have somebody that helps keep track of those emails get lost and then it just gets disappears. Um, really important that this is something that you really evaluate. What are your secondaries? How are you managing uh posting those secondary payments either when you do have an ERA? Obviously that's easier versus when you don't have an EOB or paper one and you don't have portal access. Like, how are you getting those to the billing team? And sometimes they're coming to the office, sometimes they're not coming to anybody. You have to go find them. Sometimes the payers won't release them to the uh billing company. So you have to have a process around this. All right. So if you are not sure whether your team is making these mistakes, we've actually built a free payment posting audit checklist with checks that we run in our own audits. You can download it at the at the at the link down in the show notes, eligibility.notravmd.com backslash payment dash posting dash checklist. I know that's a mouthful, so just click the link down below. It'll be easier. Um, but that way you can use uh it for your own posting processes this week. All right, mistake number three happens when we have um EOBs that come in, but the say a payer is doing some adjustments for the claim, recoupments or takebacks or anything like that, but they're not managing the recruitment. And you're in a situation where then that recruitment is put onto a claim, or maybe it's not posted at all, and you lose the opportunity for clarity around why you got a smaller check than say you should have. So for example, say you're supposed to get $1,000 from United, but they're doing a $200 recruitment. Um, if the recruitment isn't managed and then posted on the correct claim, um, you can get a situation where you're not balancing the check and working the recruitment, and then that leads to an underposting within the system or claims that aren't marked as closed or fully balanced. So then that leaves that open AR that your billing team may not have clarity because if you've missed the opportunity for the recruitment, you may not see that you need to say bill that insurance or bill that patient's new insurance. So this happens when, say, the United Healthcare pays the claim, but then United Healthcare realizes that that person's coverage wasn't actually active. So they do a recruitment. Recruitment comes in on a new check, that then you should be getting payments for new patients, but then you haven't managed the recruitment or the eligibility issue on a prior claim. And so if that process isn't clean, you can have issues with your AR not being accurate and obviously not balancing those checks and then also not resubmitting that claim. So say it was an eligibility issue, say they didn't have United at the time, they actually have Medicare now, and that wasn't caught during those first, you know, the first time that the those claims were paid, then you can be in a situation where your AR report is not going to be accurate. So obviously, why it happens, recruitments are can be tough. Um, in some certain practice management softwares, it's very difficult to post those recruitments, or it's just not as intuitive on how you post those. Good software is it's easy to post the recruitments, but you just want to make sure that the payment poster is also relaying that information to the claims team to say, hey, we have a recruitment that then now we need to go deal with that recruitment and resubmit the insurance or get the eligibility information updated or manage a denial, whatever it is, right? The recruitment claim needs to be managed. But then the posting for the full check needs to also be done. So say that $1,000, you only got paid $800, but $1,000 needs to be posted and credited to the right new patient accounts, whereas that $200 needs to be subtracted from the other account, that then that needs to, that claim then needs to go be worked or reworked. Um, I know that's sort of confusing, but you can think of it as you had a subtraction, so you need to go post that in the right account, but then everybody else who truly got their claim paid needs to have that posted, even though the the whole check is less than what you expected because of the recruitment. So, really, really important that this is done correctly and that you have this process hammered out in terms of the payment poster and the claims submission team. So, obviously, how to fix it, you're gonna be wanting to balance those checks and post those recruitments and then transfer those recruitment claims over to the claims team so that then they can manage those recruitments appropriately. Obviously, this is going to keep your AR even and accurate and make sure that your aging buckets are really focused on balances that are real work that needs to be done. All right, mistake number four. So this is all about denial codes. So when a payment comes in within an ERA or an EOB, however they come in, and you've got a denial attached to one or more of the CPTs. So say the poster logs the payment but ignores the denial remark codes or leaves the denied lines to age out in error until they're past timely filing or become infollectible. So those are those are issues when you're trying to post too quickly and you're not actually going by line by line item in the EOB and making sure that the denial codes are posted appropriately for each of the CPT codes. And so maybe you're just posting what you could post or what you did collect, but you're not managing the denials for, say, other CPTs that are on the claim that didn't get a full payment. So this can happen because if you aren't trained to read those ERAs and those codes, then there may not be education or knowledge around how to post those appropriately. Um, or you may not have a workflow for who owns the denials after the payment's posted. So denials could sit in someone else's problem bucket, but then they're not managed. And so then that AR just sits there when in reality you actually need to be managing the denial. But it's hard to see that because the denial codes weren't posted to a claim correctly. So obviously you want to make sure that when you're thinking about payment posting and denial work workflows, that you understand, okay, when a payment poster comes through a denial, how are those sent over to the team? Are they just catching them through their AR bucket review, or are you actually messaging the denial team who's managing the AR follow-up? And so, really important then to also, you know, with these denials, you can have bundling denials, right? When two CPT codes are bundled together. So one of them gets a no payment and one of them gets a payment. But if you're not putting the denial codes in there for the for the bundling and just assuming, okay, yeah, it's bundled, I'm just going to write it off. But in reality, it may be a denial code that could be appealed or worked. And then you're in a situation where you could maybe unbundle those if you had the right modifiers or the right ICD 10 codes or the right documentation or appealing. So important to make sure that those denial codes for every single one of the CPT codes are evaluated, they're connected with the CPT codes and managed with the billing team. So, really, really important that those denials, you know, for our team, the issue tracker is what we use to put those denial codes for the practice, say there's eligibility or coding denials where the practice is fixing those, or if there's medical necessity denials or, you know, those sort of issues that need to be discussed. Um, also important to configure your PM system so that those work cues, when a denial code is posted, get sent to the right person's cue or work list. Obviously, making sure that your posters are trained on those and that they're not just ignoring those denial codes or just lumping them in contractual write-offs. That's another mistake that can happen. So, to recap, obviously, we really want to make sure that payment posting mistakes aren't inflating your insurance AR. Right. So you want to make sure that everybody understands those contractual write-offs, that you're dealing with secondary missing EOBs or secondary payer payments that are coming in, making sure that you have the right information to post those, really just making sure that this workflow behind EOBs, ERAs, bank reconciliation, how those denials, if there are denials, are getting to the right team to get fixed and addressed. There's a really clear delineation of who's accountable and responsible for this and how these are all managed from a day-to-day perspective. Obviously, auditing these is really important. That's what our team does. We have several different layers of audits that occur because as you guys know, this is still, I would say, a fairly manual process. Even when you have PM softwares who are the engines behind it, there's still a lot of different puzzles and pieces between making sure that the knowledge is applied correctly in each one of the automated systems. And each system is also different. And so, really, really important that you have audits in place so that you can make sure that things are done accurately to keep an account clean. Because even if your AR metrics look really good, you can still have accuracy issues at the bottom. And so, really, really important to take a look at this. So, as I said before, if you want to see exactly, you know, those payment posting breakdowns, please download the free payment posting audit checklist. Um, link is down in the show notes. Obviously, if that checklist um shows that your AR has been inflated or you have some issues that we uh that you would like us to take a look at, we would love to meet with your practice. Um you can head on over to NetRevMD and uh check out the free revenue audit if you are looking for a new billing team and want to see if we're the right fit for you. All right, we'll talk to you soon, and I'm gonna go to the house.