Overpayment and underpayment reconciliation

Purpose

1. Automate identification and reconciliation of overpayments and underpayments from Explanation of Benefits (EOBs), Electronic Remittance Advices (ERAs), and corresponding patient/provider accounts.

2. Automates cross-verification between posted payment amounts, billed claims, patient responsibility, and insurer disbursements to detect variances.

3. Initiates automated workflows to adjust accounts, trigger refunds, generate follow-up tasks, and escalate unresolved payment discrepancies for further review.

4. Ensures all payment reconciliations are logged, communicated, and audit-trailed for compliance and financial transparency.

Trigger Conditions

1. Automated import of EOB/ERA files from insurers or clearinghouses.

2. Manual or automated batch posting of payments with outlier detection.

3. Automated flagging when amounts posted deviate from contractual fee schedules or expected patient responsibilities.

4. Triggers when refund requests, remit reversals, or payer adjustment codes are detected.

Platform Variants

1. Epic Systems

• Feature/API: Interconnect API — automate pulling payment, claim, and adjustment data; automate variance reporting configuration.
  

2. Athenahealth

• Feature/API: APIv1.0 Payments endpoint — automate reconciliation automation and discrepancy notifications.
  

3. Cerner

• Feature/Setting: Cerner Command Language (CCL) scripts — automate data queries for payment mismatches, automate alerts configuration.
  

4. eClinicalWorks

• Feature/API: eBO Reports API — automates extraction/payment anomaly reporting and reconciliation automation.
  

5. AdvancedMD

• Feature/API: Automated ERA Posting — automates the detection and exception alerts; configure batch automation schedules.
  

6. Allscripts

• Feature/Setting: Practice Management Automation Tool — automate unmatched payment identification, configure workflow automation.
  

7. Greenway Health

• Feature/API: Prime Suite Automation — automate flagging/posting errors and automate refund triggers.
  

8. Meditech

• Feature/Setting: NPR Report Writer — automate reports on payment variances, automate adjustments, automate export triggers.
  

9. Kareo

• Feature/API: Payment Reconciliation API — automate split-postings, automate discrepancy notifications.
  

10. NextGen Healthcare

• Feature/API: NextGen Connect Integration — automate detection of over/underpayments, configure automated reconciliation workflow.
  

11. Waystar

• Feature/API: Remit Manager — automate automated posting analysis and automate refund request generation.
  

12. Change Healthcare

• Feature/API: Revenue Cycle V2 API — automate matching posted/expected, automate workflows for payer response automation.
  

13. CollaborateMD

• Feature/API: Payment Posting Automation — set up automated alerts and generate reconciliation reports.
  

14. Availity

• Feature/API: Remittance Viewer & Reconciliation Automation — configure automatic discrepancy triggers and alerts.
  

15. TriZetto Provider Solutions

• Feature/Setting: ERA Reconciliation Automation — automate analysis for over and underpayments, schedule automation.
  

16. Office Ally

• Feature/API: Automated Claims Management — automate remittance import and automate payment difference reporting.
  

17. Xero

• Feature/API: Bank Feed Automation API — automate payment synchronization, automate reconciliation for patient refunds.
  

18. QuickBooks

• Feature/API: Batch Payment Reconciliation — automate importing/posting, automate exception detection for healthcare transactions.
  

19. Zoho Books

• Feature/API: API v2.0 — automate posting and reconciliation for insurance remittance matches.
  

20. SAP Concur

• Feature/API: Expense report import automation — automate reconciliation of payments/adjustments with EOBs.
  

21. Microsoft Power Automate

• Feature: Automated workflows connecting EHR, accounting, and email — automate data transfer and notification triggers.
  

22. Google Cloud Healthcare API

• Feature/API: HL7v2 to FHIR mapping — automate reconciliation between clinical and payment data sources.
  

Benefits

1. Automatedly reduces manual oversight and repetitive reconciliation tasks.

2. Accelerates revenue recognition and automates debt recovery cycles.

3. Automates error detection, thus reducing lost revenue from missed discrepancies.

4. Ensures automated audit trails for compliance.

5. Improves financial clarity, automates corrective action, and automates patient/provider communication about payment corrections.