We understand that invoices can be tricky to read and understand! This resource walks through a few example invoices ranging from really simple to more complex.
Your basic invoice
Your simplest example of a payer remit is when insurance pays with one or more adjustments and an amount owed by the patient. The associated invoice will look similar to the one below.
Balance for X Visit
The top line item Balance for OT Visit does not appear with an amount listed on the right. Click the line item to open, and you'll see the amount the patient owes. In the example above, it's $25.
X Units of X Treatment: Description (Code)
The second line item includes the code submitted, its description, the number of units submitted, and the total associate charges.
Primary Payer Adjustment
The Primary Payer Adjustment is any amount not paid by the payer or assigned to the patient. Payers use adjustment codes to allocate claims, and the full breakdown can be found on the actual remit.
Primary Payer Paid Amount
The last line item shows what the primary payer paid on the claim.
Note: If you take the total charges and subtract the adjustments and primary paid amount, it will equal the amount that the patient is being billed for. As seen below, this amount will be reflected on the patient's invoice.
Re-adjudicated payments
Invoices will look more complicated when a payer re-adjudicates, meaning they changed their payment allocation. Payers will alter their adjudication for any number of reasons, but it's important to note that these re-adjudications will appear on the invoice, like the one below.
Context: Let's think through the adjudications leading to the invoice above. First, the payer processed $80 towards patient deductible and the remaining $20 as not allowed. Then the payer came back and reprocessed! The original deductible adjudication has been reversed (think "voided") and now the payer has paid $50, assigned $25 to the patient as a co-pay, and written off the remaining $25 as not allowed.
Balance for X Visit
The top line item Balance for OT Visit does not appear with an amount listed on the right. Click the line item to open, and you'll see the amount the patient owes. In the example above, it's $25.
X Units of X Treatment: Description (Code)
The second line item includes the code submitted, its description, the number of units submitted, and the total associated charges.
Primary Payer Adjustment
This line will show the true adjustment amount. Remember, the payer sent back two remits - the original one that was later corrected and the final one. The original remit was reversed in Fusion (or "voided"), so the invoice isn't considering the payer's original $20 adjustment, only the $25 adjustment on the newest and correct remit. Always go back to the remit itself to understand the full picture!
Re-Adjudicated
The next two lines are the re-adjudications from the original and incorrect remit. Although it was ultimately incorrect, it's still a Primary Payer Adjustment and is reflected on the invoice.
Primary Payer Paid Amount
The last line item shows what the primary payer paid on the claim.
Note: To recap, you can read this by saying "Primary initially paid $0, re-adjudicated and paid $50, wrote off $25, and assigned the remaining $25 to the patient as a co-pay." When you add up all the amounts in the right column, you get the $25 the patient owes!
Amounts present on other invoices
In the second example above, we created invoices only after the payer re-adjudicated the claim with the correct amount. Because we waited for the correct adjudication, our invoice to the patient was accurate. Now what if we invoice a patient for the original adjudication and later learn it was incorrect?
Example 1
You have a claim process towards deductible, you finalize it, and the patient is invoiced and billed, but they come back telling you they don't owe that amount. We call the payer and the claim is reprocessed correctly with the patient only owing a $25 co-pay. How do we correct the patient's invoice?
First, understand that Fusion will not automatically adjust any created invoices after an adjudication changes. It assumes the patient paid the invoiced amount. You'll need to open the original invoice showing the $80 deductible charge and remove the line from the invoice. You'll notice a new line item in the Uninvoiced section with the correct $25 co-pay amount. Now you can invoice this new line item and bill the patient per your normal process.
Example 2
Let's take the same example above where the payer originally assigned an $80 deductible, you invoiced the patient, and then the payer re-adjudicated assigning only a $25 co-pay to the patient - except, this time, the patient paid the $80 and has overpaid. We don't want to edit the invoice like in Example 1 because the patient truly made an $80 payment. Instead, once you finalize the correct payment from the payer, you'll see a credit appear in your Uninvoiced section for $55 (the difference between the $80 original charge and the now $25 co-pay). You can now apply that $55 dollars to another invoice as a credit or complete a refund.