Submitted is a stage
A submitted claim has entered a process. It is not evidence that the payer has approved or paid it.
Understanding collectionsFollow the claim.
Follow the claim.
Understand the numbers.
Charges, payer decisions, and collections describe different stages of the financial workflow. Keeping them separate gives your business a more useful picture.
Discuss your next stepPaid needs context
A payer payment may reflect adjustments, patient responsibility, and other claim-specific decisions.
Collections can change
Refunds, recoupments, and later adjustments may affect previously received amounts.
THE FIELD NOTES / 01
1. Before a claim is submitted
Eligibility review, clinical documentation, coding, and any relevant authorization requirements help establish the submission pathway. An eligibility response is not a guarantee that the eventual claim will be paid.
- Confirm the specific patient plan and benefits
- Follow the approved clinical and documentation workflow
- Review applicable authorization and coding requirements
- Submit through the designated billing arrangement
THE FIELD NOTES / 02
2. After the payer responds
The payer may pay, deny, request information, or apply adjustments. Operational reporting should show the response and the responsible next step, rather than presenting every submitted amount as revenue.
- Track claim status and payer responses
- Separate paid, outstanding, and denied items
- Record adjustments and patient responsibility
- Follow the agreed exception and denial process
THE FIELD NOTES / 03
3. When financial results are reconciled
The program’s agreement defines how actual receipts and adjustments affect any clinic compensation. A useful reconciliation connects collections to the approved methodology and identifies subsequent changes.
- Distinguish billed charges from actual receipts
- Apply documented refunds, recoupments, and adjustments
- Use the approved service-specific compensation terms
- Review statements and resolve discrepancies through the agreed channel
THE QUESTIONS THAT MATTERA little more
A little more
clarity.
Can we forecast using billed charges?
Billed charges alone do not establish expected collections. Any financial model needs clearly stated assumptions about payer outcomes, adjustments, timing, costs, and the applicable agreement.
Is there a standard reimbursement amount for every visit?
No. Payment depends on the payer product, service, provider arrangement, coding, patient benefits, and other claim-specific conditions.
When does the clinic receive payment?
The written program terms govern any clinic compensation and its timing. Do not assume that a submission, approval, or payment notification automatically creates an immediate payout.
THE NEXT MOVE IS YOURS.LET’S MAKE IT HAPPEN. ↗
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