Objective :

Oversee credit balance accounts to identify, validate, and resolve overpayments, ensuring accurate and timely refunds to patients, payers, or other funding sources in full compliance with regulatory and contractual obligations.

Key Responsibilities :

Credit Balance Identification :

Purpose : Accurately detect credit balances through routine account reviews and system reporting.

Tasks:

  • Run regular credit balance reports from the billing system or EHR.
  • Identify credits due to:
  • Duplicate payments
  • Coordination of benefits (COB) errors
  • Incorrect posting (payer vs. patient)
  • Contractual adjustments or misapplied write-offs
  • Flag high-dollar or payer-sensitive accounts for priority resolution.

Root Cause Analysis & Validation :

Purpose : Confirm the legitimacy and source of the credit balance before initiating refund or adjustment.

Audit :

  • Payment and remittance history (ERA/EOB)
  • Patient demographics and insurance details
  • Secondary payer status and COB documentation
  • Determine if the credit is valid and refundable Due to a posting error (requiring correction, not refund) To be transferred to another open balance.

Refund Processing :

Purpose : Issue timely and accurate refunds to the appropriate party (payer, patient, or guarantor).

Tasks :

  • Generate and route refund requests per internal policy.
  • Process refunds within payer-specific or regulatory timelines.
  • Document all refund transactions, including:
  • Reason for overpayment
  • Funding source (e.g., payer, patient, HSA/FSA)
  • Date and amount refunded
  • Coordinate with accounting or finance teams to reconcile balances.

Compliance & Reporting :

Purpose : Maintain adherence to federal, state, and payer refund regulations (e.g., CMS, state Medicaid, commercial payers).

Tasks :

  • Monitor deadlines for credit balance resolution (e.g., 30–60 days).
  • Ensure compliance with:
  • Medicare credit balance reporting (CMS-838)
  • State Medicaid refund policies
  • Commercial payer agreements
  • Maintain a detailed credit balance audit log for internal and external audits.

Our Best Practices:

  • Establish a weekly credit balance review process.
  • Implement threshold-based alerts for high-dollar credits.
  • Train billing and posting staff on common causes of credit creation.
  • Use workflow automation tools to route and track refund requests.

Why It’s Important :

Effective credit balance management protects your organization from regulatory fines, payer audits, and cash flow distortion, while also reinforcing patient trust and financial integrity.