What to expect, 5 of 7Read this when a copay, balance, or credit does not look right.
Benefit checks, copays, balances, and credits.
How we verify benefits and how accurate it is, how copays get charged and corrected, why balances and credits happen, and who talks to the client.
Benefit checks (VOB)
- 1
Every new client, about two weeks ahead
As soon as a client with insurance is on your schedule, we run an electronic eligibility check. When it is unclear (a deductible plan, a carve-out, an employer plan we have not seen), we call the payer. You do not have to ask.
- 2
Ask for a quote when you want one for the client
Reply to any email with "VOB for [client]" and George sends a short, copy-paste summary: in or out of network, copay or coinsurance, deductible and how much is met, visit limits, whether telehealth is covered. Send it to the client as an estimate.
- 3
About 93% right the first time
A benefit check is an estimate: payer systems lag plan changes, deductibles are the usual miss, and January resets catch everyone. When the EOB disagrees with the check, we correct the ledger and say so in the Monday email.
- 4
Out of network or inactive
We flag it before the session and ask: self-pay, bill out of network, or reschedule until coverage is sorted. We do not bill a session as in-network when the check says otherwise.
Copay, coinsurance, deductible, in one example
A plan with a $500 deductible, then 20% coinsurance, on a $150 session: the first few sessions are the client’s to pay until $500 is met, then the client owes $30 and the plan pays $120. A plan with a $25 copay owes $25 every session regardless. The benefit check tells us which kind the client has and how much of the deductible is already met; the claim confirms it.
Copays and client payments
- 1
Charged the morning after the session
The estimated copay or coinsurance goes to the card on file the next morning, with the claim, under the card-on-file consent your client gave when they added the card. No-show and late-cancel fees are charged the same way, using the fees in your policy where the payer allows them (many Medicaid plans do not). Missed-visit fees are never billed to insurance.
- 2
Corrected when the EOB arrives
If the payer says the client owed more, we charge the difference. If less, we credit it. Differences under about $50 we handle within that card-on-file consent; larger ones come to you first. Clients with Medicaid as a secondary, or Medicare’s Qualified Medicare Beneficiary status, cannot be charged Medicare cost sharing at all; we flag those.
- 3
A declined card comes to you
We retry once, then tell you in the Monday email. You ask the client for a new card; we never contact them.
- 4
Cash and checks
If a client pays you directly, record it in the EHR the same day. We cannot see cash, so an unrecorded payment shows up as a balance.
Why a balance or credit happens
Balance, "card declined"
Usual cause: Expired card, new card, or a limit.
What we do: Retry once, then ask you to get a new card from the client. Automatic charges pause until you tell us to resume.
Balance, "deductible"
Usual cause: The plan applied the session to an unmet deductible, often in January.
What we do: Charge the card if the amount is small and the client has agreed to card-on-file; otherwise ask you.
Balance, "no card on file"
Usual cause: The client never added a card, or it was removed.
What we do: Ask you to have the client add one through the portal.
Balance, "before start date"
Usual cause: Sessions before Bomi started, handled by you or a previous biller.
What we do: Report it. We work it only if you ask.
Credit
Usual cause: Payer paid more than estimated, or a card was charged before the EOB came back.
What we do: Apply to the next session by default. Refund to the card if you say so.
A payer says it overpaid
Usual cause: The payer wants money back from the practice. This is not a client credit.
What we do: Verify it against the remittance first; payers are sometimes wrong, and some can offset instead of a refund.
Large balance or credit
Usual cause: Several sessions of the same issue, or a plan change mid-treatment.
What we do: Bring it to you with options: charge, payment plan, write off, or you talk to the client.
What you can tell us, any time
- Never auto-charge this client; I will handle them.
- This client is self-pay at $X; do not bill their insurance.
- Set up a payment plan of $X a month for this client’s deductible balance.
- Pause automatic payments for this client until [date].
- Refund credits instead of applying them.
- Write off balances under $X.
- Old balances from before our start date: work them, or leave them.
We do not do collections
We keep balances small by charging the morning after and catching problems the same week. If a client stops paying, the conversation is yours, and we tell you exactly what they owe and why.