Insurance Adjustments

The difference between the UCR fee and the negotiated rate of the insurance carrier for a given procedure.

Insurance Adjustments

• Insurance Adjustment may be different from the UCR fee minus the negotiated rate if:
  • The total patient responsibility plus the insurance payment is greater than or less than the negotiated rate
• To avoid changes to the insurance adjustment amount:
  • Keep fee schedules up to date
  • Don’t record a patient responsibility and insurance payment on a claim that does not equal the negotiated rate.
• An example of when the insurance adjustment is not the difference between the UCR and the Negotiated Rate
  • The office UCR for a procedure is $500. The negotiated rate is $350. The estimated insurance writeoff (adjustment) is $150.
  • When the claim is processed, the employee records an insurance payment of $300 and a patient responsibility of $25, which totals $325.
  • This updates the insurance adjustment to $175 rather than the original $150.