Denial, Balance Billing, Capitation Payment

• Denial :
Denial is the technical term used for the non-payment of a claim by the insurance. The insurance usually pays the claim if the details presented to them are sufficient enough for processing. If there is any lack of information then the insurance quotes a reason for which the claim is not considered for payment which is known to be the denial reason. These reasons are found in the EOB. Some insurance like Medicare follow a general set of denial codes which is uniform across all the states. But some commercial insurance follow their own set of reasons codes for the denials which will be clearly mentioned in the EOB.
For Example:-
If the claim has gone to the insurance without the patient date of birth then the insurance will not pay the claim stating a denial reason code to it.

• Balance Billing:
It is the difference between the billed amount and the amount approved by insurance. Once the claim payment had been made by the primary insurance and if there is any balance pending for the claim then the balance is either sent to the secondary payor or to the patient.
If the patient is enrolled with the secondary payor then the balance is billed to it. Generally for secondary billing the claim must be submitted along with the primary payor’s EOB. Only then the secondary payor will pay for the claim. In secondary billing primary payor EOB is the most important document. Some insurance like Medicare automatically transfers the pending balance to the secondary payer (Medicare Supplementary) if the patient has any. This procedure is termed as Crossover which reduces the work of the billing office.
If the patient is not enrolled with the secondary payor then the balance is billed to the patient. Patient billing cannot be done at all the cases. For certain cases we need the client’s approval for patient billing. Periodic patient statements are sent to the patient in order to intimate the balance which is pending from patient.

• Capitation Payment:-
Specified amount paid periodically to the provider for a group of specified health services, regardless of quantity rendered. This is a method of payment in which the provider is paid a fixed amount for each person served no matter what the actual number or nature of services delivered. The cost of providing an individual with a specific set of services over a set period of time, usually a month or a year. It is a payment system where managed care plans pay the health care providers a fixed amount to care for a patient over a given period. Providers are not reimbursed for services that exceed the allotted amount. The rate may be fixed for all members or it can be adjusted for the age and gender of the member.
Now let us see the diagrammatic representation of the cash posting process: