Insurance Accounts Receivable

Insurance A/R services focus specifically on follow-up and resolution of outstanding claims with insurance payers, tracking unpaid or underpaid claims, appealing denials, and maximizing reimbursement from commercial and government payers.

Claims are generated in the 837 format and submitted with all required patient, diagnosis, and procedure details. They are then tracked through the revenue cycle to ensure timely processing and payment.

Financial teams investigate the denial reasons, such as coding errors or missing documentation, correct the issues, and either resubmit the claims or initiate the appeals process.

Payments are posted upon receipt, including both primary and secondary payments. They are reconciled with electronic remittance advice (ERA) to ensure accuracy and identify any discrepancies.

Aging analysis categorizes outstanding claims based on how long they’ve been unpaid (e.g., 30, 60, 90 days). It helps teams prioritize follow-ups and reduce A/R days.

Payment variance analysis compares expected and actual payments. Discrepancies are investigated and resolved, while approved write-offs are documented based on contractual or regulatory guidelines.

Revenue cycle management software is used to streamline claims processing, automate payment posting, analyze performance, and generate reports on key A/R metrics and trends.

Insurance A/R involves following up with payers on submitted claims, while self-pay A/R focuses on collecting balances directly from patients. Both require different workflows, communication strategies, and expertise.

Key metrics include days in A/R, clean claim rate, denial rate, first-pass resolution rate, and percentage of A/R over 90/120 days.