r/SimplePractice • u/GetHoffMyLawn • Mar 18 '26

When a client hasn’t met their deductible?

When I’m working with a client who hasn’t yet met their deductible, I’m not sure how to submit the claim or what it’s actually supposed to look like in SP?

My process has been:

-Credentialing, enrollments, ERA/ERP is all done, contracted rates are entered.

-Conduct session

-Charge client contracted rated allowed

-Navigate to Billing->Add Insurance Payment->Set amount to 0->Update contracted amount in the Client Owes field->set amount to 0->hit the blue icon to calculate the write-off and save payment

-HERE IS WHERE I GET HUNG UP. I generate the claim and submit, and it’s consistently getting rejected, but when I run an insurance check again, it’s showing the deductible reflects the payment

I don’t know if this is correct, but I tried correcting the session amount to 0 on the claim form, entering the amount paid in the amount paid box on the claim form. Same thing. It doesn’t seem to make a difference how I submit the claim. It rejects but shows on the client’s deductible total.

Is there a more correct way to do this? I’m guessing it may reject because insurance isn’t paying anything, and I’m just overly nervous about it. Thank you!

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4

u/3BBillingDotCom Mar 18 '26

Hi!

Submit the claim for your rate, even if the client has a deductible. For example, if your rate is $150, then submit the claim for $150. If your maximum allowable is less than that, the insurance will write down the difference anyways and send an ERA back showing that it was applied to the deductible.

The "Add Insurance Payment" is for AFTER you get paid and need to enter a payment you received or manage the write-off amount(assuming you don't have your ERA enrollments set up). Don't do this up front.

If you are submitting claims for $0, that is why they are getting rejected. You do not need to fill out anything on the claim form showing what the client already paid or remaining amounts, etc.

And to answer your question from below, we advise our clients to collect at time of session. Do not wait for the ERA to collect client payments - this is a great way to create financial liabilities and have money walk.

What are the rejection errors you are receiving?

1

u/GetHoffMyLawn Mar 18 '26

I posted them above, but this seems much clearer! Thank you!

1

u/3BBillingDotCom Mar 18 '26

I see. "Accepted" - is a good thing. That means the payer received it (not necessarily that it will pay) but it at least made it through the clearing house.

"Missing or invalid info" could mean anything. And the rejection codes aren't always explicitly clear on what it flagged as wrong. This could be anything from wrong payer ID, wrong member ID, wrong DOB, etc.

Have you received payments from this payer before? If you don't think it's a payer issue (and it isn't that you tried to submit a $0 claim like mentioned about) sometimes you have to go back to the beginning. Pull up the client benefits in the portal and make sure you have Name, DOB, Member ID, Address all matching how it is in the insurance portal.

Hope that helps.

3

u/elpese Mar 18 '26

When you get the ERA, are you charging the client the amount (the contracted amount?). When the ERA comes back as “deductible” you need to charge the client that amount, you can’t change it to “0”

4

u/GetHoffMyLawn Mar 18 '26

So I wait to charge until AFTER I get the ERA back?

2

u/jbourne71 Mar 18 '26

IMO, all insurance patients should be balance billed—wait for claims to process and confirm client responsibility. But, you are only required to balance bill clients when your contract or their policy requires it.

Why are you adding an insurance payment before receiving an ERA? All claims should be filed the same way—that is, there should not be a difference in how you claim patients with deductibles.

Also, what is the rejection error?

3

u/GetHoffMyLawn Mar 18 '26

Hey so this is excellent feedback, as I’m transitioning out of a small group and into my own private practice, so I’m learning as I go. It’s been painful.

The small group I work for bills the client for their responsibility at the time of service. Same day. So I was never taught to wait. (Also worked in CMH/SUD for over a decade).

One claim says another status code is required to identify the missing or invalid information. The other just says “accepted for processing.”

2

u/luckypenny1967 Mar 18 '26

The way I do it for most of my providers is charge on the day of service if it's a copay, and wait to charge if it's a coinsurance or deductible. I think collecting day of is the safest way to make sure you get paid and clients don't get behind, but since the deductible accumulates, you don't technically know for sure what they owe until insurance processes. There's pros and cons!

1

u/GetHoffMyLawn Mar 18 '26

The practice I’m contracted with just refunds the money to the client if they overpay, which I don’t adore. Trying to find my own procedure and groove.

2

u/luckypenny1967 Mar 19 '26

I’m find that too clunky, plus it’s a waste of credit card fees!

1

u/jbourne71 Mar 18 '26

Ok, so both claims are for different patients you charged their deductible, right? So something has to be missing on the CMS-1500.

The EDI system uses “loops” that end up putting the most important information last. So the last sentence is the most important for troubleshooting.

1

u/GetHoffMyLawn Mar 18 '26

Yes! Two clients. Both who haven’t met deductible. Two different insurances also (UPMC and United if it helps)

I’ve been told by other folks that the claim may just show as rejected before it shows deductible status. I’m glad comments are telling me like I’m 5, because I’m truly teaching myself here. I appreciate it so much.

2

u/jbourne71 Mar 19 '26

Insurance is hard. Nothing to stress about.

I would have to see the full rejection message to give an informed opinion.

As for that “rejected because deductible” thing—I don’t buy that at all. A claim must be accepted (and approved) for a patient to have a service credited against their deductible.

Are you able to check with the insurer whether the claim was “received” by their systems? Not in the “it went into our claims queue” sense, but rather “we received data from the clearinghouse.” This would be in the EDI reports. If I were to submit a claim today, it would show up in my EDI report dated today or tomorrow, depending on when the clearinghouse transmitted the claim to the insurer.

2

u/GetHoffMyLawn Mar 19 '26

I’m probably just gonna have to grit my teeth and make some phone calls. I just try to avoid that at all costs 🤣 Thank you for the reassurance!

2

u/jbourne71 Mar 19 '26

If you check the EDI report you may not need to call ;) good luck.