Provider Level PLB Adjustments

Efficiently Managing Provider Level Adjustments

What Are Provider Level Adjustments?

Provider Level Balance Adjustments (aka PLBs) are used to convey adjustment information in 835 files that can increase or decrease healthcare provider payments. It can be confusing to follow and determine what is truly owed for a claim because overpayments are often made by healthcare insurance companies, or interest might have accrued due to late payments. The insurance companies (i.e., payors) will then send correspondence to the provider organizations requesting a refund for the overpaid claim. They will then either receive a refund to be processed for the overpaid amount, or they will not receive a refund in the time allotted. That balance will then move forward to a future 835 file for overpayment recovery.

Within a multi-hospital, multi-practice organization, the process of identifying a particular business unit or practice group associated with these provider level adjustments becomes exponentially more complex. This is often complicated by the variety and/or lack of information which can be useful to re-associate these transactions to a particular division or practice.

In some cases, there may be multiple offsetting adjustments across multiple checks as forwarding balances are worked off. It is also possible that items may still be “in progress” from a payor.

While it may require a fair amount of research to tie everything together, some payors may have documentation on how they manage Provider Level Adjustments. If all else fails and a resolution cannot be found, you may need to call the payor to ask for more details to help with the research process.

By leveraging a single cash management platform, RCMS ReSolve® manages the data capture, parsing & batch balancing, validation, and bank reconciliation for multiple EMR/Host Billing and Practice Management Systems.

RCMS automated workflows and worklisting tools can increase efficiency, improve data accuracy, generate work queues and many other time-saving benefits. Contact Us today to schedule a call or presentation.

Editor’s Note:
A version of this article was originally published by ReMedics, LLC in “A Closer Look” client newsletter that deals with common payment processing, denial/defect and reconciliation issues. ReMedics is a sister company of RCMS, LLC with common ownership.

Automated EDI Parsing Splitting Software

Case Study: Automated Parsing of EDI Transactions

Client Background:

The client is a large podiatry practice group that provides a full range of specialty services for the advanced treatment of foot and lower extremity conditions. The group has over 100 board certified podiatrists, providing medical services through a network of approximately 80 office locations. They are backed by a private equity investment firm that specializes in healthcare service investments.


The payment posting team was receiving EDI transaction payments for multiple business units/divisions within a single ERA file from their clearinghouse. Further complicating matters, each practice was being migrated to a new Practice Management platform as part of their onboarding process. In order to process remittances more efficiently and reduce work on the back-end of the revenue cycle, they needed a solution that could split payment data to the appropriate business unit’s practice management (PM) system as it was being received.

They also had a requirement to automate the splitting of payments processed without matching claim data. These payments included claims billed with attachments, as well as secondary billing, worker’s compensation, and other requirements for processing outside of the submitting clearinghouse.

The Solution:

  • ANSI 835 files are received from the client’s clearinghouse on a daily basis, where ERA/EDI files are ingested into a proprietary Single Cash Management System solution for data splitting, validation, and reconciliation.
  • Data is matched against corresponding claim feeds (ANSI 837 files) and reconciled to updated check/batch data contained within the ANSI 835 transactions.
  • Through custom configuration and multi-level splitting logic contained within the processing solution, corresponding payments and denial data are assigned to the appropriate EMR or PM system.
  • An optional RCMS hosted document management system is available to index and retrieve all transactional payment/ERA data for EOB storage and retrieval.

The Results:

Using advanced data capture and Business Process Automation (BPA) technology, RCMS ensures that all updated and re-balanced payment files are distributed to each business unit on a daily basis — and reconciled back to the check and original 835 file received from the Clearinghouse. The client no longer has to split and transfer payments “downstream” for each business unit, resulting in more timely and consistent cash flow.

Daily payment balancing and posting reports are delivered to the client to assist with distribution, reconciliation, and identification of processed work. RCMS also provides a separate electronic 835 ERA file and corresponding reports for any transactions that do not qualify for a pre-defined entity, such as transactions that contain any unidentified payments for external systems that fall outside of the project scope.

Due to the efficiencies created by these services, the client is able to devote more time towards business expansion initiatives. Client personnel can now quickly search and retrieve electronic files by Business Unit, Patient Name, Check Number, Service Date, Paid Amount and many other options to quickly identify information needed for payment posting or follow-up activities.

Positioned for Growth

With the RCMS technology in place, new business units can quickly be added to the Client’s existing EDI splitting and payment processing services — while continuing to use their current practice management system(s). By adopting a multi-submitter, single receiver workflow to capture all their payments, acquired or merged groups maintain their billing autonomy while reporting up to a single corporate Tax ID through their PM system conversion plan. At a future date in time, RCMS can help to develop and implement a systems migration strategy to a common platform.

Editor’s note: this case study was also published by ReMedics LLC, our sister BPO services company that provides outsourced remittance processing, data validation and bank reconciliation support to physician practice groups and management services organizations (MSOs) throughout the United States.

Contact RCMS

RCMS can deliver proven EDI data capture and parsing solutions that provide for significant productivity gains in your business office. Contact RCMS about improving staff efficiency and organizing your business information.