Question: Do hospitals and physician practices use small balance adjustments to effectively resolve certain accounts? How is this employed for insurance balances and patient balances? What implications does the patient's insurance (e.g., Medicare, private) have on these policies?

Answer 1: Our physicians adjust small balance write-offs for both insurance and patient balances under these circumstances:

  • Insurance: When the age of the claim reaches more than 60 days and the balance is less than $5.00, the balance is adjusted off as a miscellaneous adjustment.
  • Insurance: When the insurance credit balance is less than $9.99, we adjust off the balance to third-party recovery; this notates the account so that if the insurance company requests this at a later time, we can view this in our system, reverse adjustment, and refund, if necessary.
  • Medicare, Medicaid, or BCBS: All balances refunded.
  • Self-pay credit balances. Amounts less than $9.99 are recovered to self-pay small balance adjustments (credits are moved later to future encounters)
  • Self-pay balances: Amounts less than $9.99 are adjusted every 150 days to self-pay small balance adjustments.

Our policy is to refund amounts greater than $9.99 for both patient and insurance credit balances, unless a refund is requested.

We have now signed up for auto recoupment for Medicare credit balances so that we will not be charged penalties in the delay of a refund due. Medicaid credit balances are all sent individually by a form with voucher information attached. Credit balances remain on account until the state Medicaid department recoups/re-applies funds from current/active vouchers.

This question was answered by Keith Moore, FHFMA, CFO, HSHS Medical Group, Springfield, Ill., and a member of the McMahon Illini Chapter (

Answer 2: There are many points of view on this topic, but here is how our facility handles these scenarios.

We process and refund Medicare and Medicaid for all overpayment dollars and re-bill accounts when it is appropriate. We list the Medicare credit balances on the Medicare credit balance report, if required.

For private insurance, we auto write off $4.99 debits and credits via a small balance write-off routine. If a payer requests a refund, we will review it at that time.

For self-pay, our policy specifies that we may transfer over payments to other open accounts by the guarantor to satisfy outstanding patient balances. The small balance write off of $4.99 applies against the self-pay debits and credits. If we are contacted about a small balance self-pay credit, we review it.

This question was answered by Steve Marshall, director of patient financial services, Margaret R. Pardee Memorial Hospital, Hendersonville, N.C., and a member of HFMA's North Carolina Chapter ( 

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Publication Date: Wednesday, October 24, 2012