Healthcare Technology Featured Article

November 14, 2016

Three Smart Ways to Examine Your Payment Variances


Healthcare reforms keep on bringing new guidelines and regulations in the medical industry. These guidelines have a huge impact on the business, revenue generation and overall profits that can be attained by the physicians. The medical industry is made to embrace the new technology (EMR, EHR or Practice Mate) with the coming of these reforms.

 It becomes the responsibility of the practice or physician to make prudent decisions for maintaining a high level of service and quality practices. Keeping everyone informed in the office about the sphere of service and financial components is simply the smart way of doing things.

According to a report from CMS (Center for Medical Services), Medicare denials include 11 percent of claims that are submitted and 40 percent of those claims which are never resubmitted. Medicare data even revealed that 65 percent of claims which are reviewed on appeal are eventually paid, which means increased payments.

The American Medical Association found in their Health Insurance Report Card that, with a complex reimbursement and coding system, the accuracy rate in payments among insurance companies has dipped as low as 77 percent. Here, we will discuss the smarter ways to examine Payment Variances

1. Learn About Your Payment

From where does the revenue chain start? Some people believe that it starts when the charges of the patients are entered in the computer, but it actually starts as soon as the patient first calls and ends when the amount is completely paid. For identifying your underpayments, you need to make sure you know how much you are owed.

You need to ask your insurance companies to give you a current fee schedule. All you really require is the top 50 CPT codes with their rates and including modifiers. Few companies may delay or ignore your request; in this situation you can go to the Center for Medicare Medical Services(CMS), which equips you with online lookup tools for Medicare.

 2. Process to Ensure Payments are Correct

The first step is to get your payment in hand and then ensure that you receive it appropriately every time. You can use the power of automation (practice management system), which stores the scheduled payers’ rate and also cross-checks each item automatically.  Comparing the expected rate and the EOB will allow you to alter your variances automatically between what should have been paid and what has actually been paid. The cross checking of EOBs can be executed on electronic remittances.

You also need to follow the denial claims and underpayment with the same tenacity and vigor. Your underpayment and denials should be identified on line item ground; never accept reimbursement of one line item to be considered as “payment in full.”

3. Allowable From Insurance Company

The allowable from the Insurance Company reflects the aggregate amount you are allowed to collect from the beneficiary and from the insurer. Earlier, insurance companies used to owe a major share of the allowable.

 With the increase in deductible health plans and growth in employers selecting insurance policies with higher coinsurance and co-payments, patients are now paying a greater portion of the cost of healthcare. In case you feel that you are receiving less for the contracted services, you should never turn a blind eye towards the unmet deductibles, overdue co-insurance or skipped co-payments from the patients. You need to put an effective method of collecting cash from patients and their insurance companies in place.

It is your responsibility to advance the quality of internal services and systems to avoid the payment variances. There is a need to streamline the process and discard those without value. If your practice is failing in maintaining optimal performance, then it is time to hire an outsourcing company for their expertise. But, no matter what, keep your company and patients in check by following the above mentioned tips on how to safeguard your deserved payment.




Edited by Alicia Young
By Special Guest
Veronica Hanks, Senior Business Analyst, Algoworks ,





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