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Reimbursement Methodologies and Patient Financials
Reimbursement is how providers get paid and how patient responsibility is calculated. Expect math: coinsurance and deductibles are figured from the allowed amount, not the billed charge.
Allowed Amount and Patient Responsibility
The allowed amount is the maximum a payer recognizes for a covered service, often less than the billed charge.
Coinsurance and deductibles are calculated from the allowed amount, not the billed charge.
For a participating provider, the difference between the billed charge and the allowed amount is a contractual write-off and cannot be balance-billed.
The out-of-pocket maximum caps a patient's cost-sharing in a benefit period, after which the plan pays 100% of covered services.
Cost-Sharing Definitions
A copay is a fixed dollar amount paid per covered service, such as an office visit.
A deductible is the amount the patient must pay each benefit period before the plan begins to pay.
Coinsurance is a percentage of the allowed amount the patient owes after the deductible is met.
Physician and Facility Payment Systems
RBRVS sets physician payment from relative value units for work, practice expense, and malpractice, adjusted geographically and multiplied by a conversion factor.
DRGs pay a fixed amount per inpatient admission by grouping clinically similar cases; APCs are the outpatient facility counterpart.
Capitation pays a fixed amount per member per month regardless of services used, while fee-for-service pays separately for each service.
Reimbursement Math Example
With a $1,000 allowed amount, a met deductible, and 20% coinsurance, the patient owes $200 and the payer pays $800.
When a deductible remains, subtract it first, then apply coinsurance to the remaining allowed amount.
Balance billing is charging the patient the gap between the charge and the allowed amount; it is generally prohibited for participating providers.
Collections and Payment Posting
Accounts receivable aging sorts unpaid balances by age (such as 30, 60, or 90 days) to prioritize follow-up.
Payment posting records the amount paid, applies contractual adjustments, and moves the correct remaining balance to the patient or secondary payer.
Patient statements should itemize services, charges, insurance payments and adjustments, and the balance due.
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Last updated: July 2026