Contractual Adjustments
Contractual adjustments reflect the difference between a provider’s billed amount and the payment allowed by an insurance contract. These adjustments occur for a variety of reasons, including billing above the contracted rate, expired policies, missing authorizations, or missed deadlines. The adjustment is automatically calculated once the insurance payer specifies the reason through a code and description.
Adjustment codes and descriptions clarify the reason for non-payment or reduction. Lightning Step displays this information in the remittance advice and highlights relevant details in claim records.
When a contractual adjustment is applied, the outstanding claim balance is updated to reflect the reduced collectible amount. If the adjustment results in a denial, claims are flagged in the Denied Claims bucket and included in the Denial Report for review. This setup allows for effective monitoring and follow-up of any denied charges, ensuring prompt resolution.
Patient Responsibility Adjustments
Patient responsibility refers to the portion of the charges insurance designates for the patient to pay. Common reasons include deductibles, coinsurance, copays, or non-covered services. Lightning Step clearly identifies the responsible party within claim records using detailed codes and descriptions supplied by insurance.
Once patient responsibility is updated, the claim’s insurance balance decreases, and the corresponding patient account balance increases.
Charges designated as patient responsibility are flagged in client accounts, making them ready for invoicing and inclusion on statements.
Key Considerations
Accurate management of contractual adjustments and patient responsibility in Lightning Step RCM ensures claims and accounts reflect true balances. Proper interpretation of adjustment codes and regular review of denied claims are vital for maintaining compliant and efficient billing workflows. When in doubt, utilizing internal resources or reaching out to Lightning Step support can help clarify questions and resolve issues quickly.
