Tag Archives: PLB adjustments

Provider Level PLB Adjustments

Efficiently Managing Provider Level Balance Adjustments (PLBs)

Posted on

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.

Re-Association of PLB Transactions

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.

RCMS utilizes information provided by the insurance payors, along with any previous payment information collected, to identify the division or practice group for as many of these transactions as possible. For those adjustments that cannot be easily associated to a practice, the ReSolve­® A/R Management Platform provides automated worklists identifying associated funds so they can be efficiently identified and appropriately transferred.

Multiple Offsetting Adjustments

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.

Working with RCMS 

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.

PLB adjustments lookup

Streamlined PLB Adjustments with Payment History and ICN

Posted on

RCMS automated workflows and worklisting tools can increase efficiency, improve data accuracy, generate work queues and many other time-saving benefits. Identifying Provider Level Adjustments (PLB) within your ERA payments is just one example of how systems integration and workflow automation can be utilized to reduce and often eliminate manual data-entry tasks.

ERAs and Provider Level Adjustments

Provider level adjustments are reported in the 835 ERA records received by healthcare providers from insurers. PLB adjustments can decrease the payment or increase the payment depending on each remittance. In order to post payments into the patient accounting system, PLB information must be taken into consideration.

According to American Medical Association, “The ERA can include multiple types of reductions that are not specific to a claim reported in that ERA, or even reductions and payments not related to claims at all. Since the ERA is intended for computer processing, it is important that the Practice Management Systems track these adjustments back to the original claims, when appropriate, for automation and basic validation.”

Examples of provider level adjustments include:

  1. Recovery of overpayments
  2. Balance forward (when recovery of overpayments exceeds payments in a specific ERA)
  3. IRS withholding
  4. Capitation payments
  5. Performance bonuses
  6. Interest payments
  7. Recovery check acknowledgment

See the American Medical Association’s document Electronic Remittance Advice Processing Tips for additional information.

Driving Automation in the Revenue Cycle

Balancing for a single remittance that requires the total paid amount be equal to the total submitted charges (after PLB adjustments) can be labor intensive. Systems integration technology that connects all of the patient, insurance, claim and payment information, can provide significant opportunities to reduce manual work processes. With the use of Enterprise Content Management (ECM) and automated data validation rules, many of today’s patient accounting challenges can be enhanced and streamlined. Where the data is available, RCMS can automatically populate PLB adjustments that result in a zero balance for auto-posting. The key is having access to real-time data in order to drive automation and create greater efficiencies. Where adjustments can’t be identified, we create worklisting tools with the payment history and ICN information for staff to more effectively process the remittance prior to posting.

About RCMS

RCMS brings decades of healthcare business office experience to improve your revenue cycle. Our solutions are customized to work with your core applications and deliver significant time-saving improvements throughout the organization. Contact RCMS about improving your workflow processes.