Waterfall Billing

Waterfall Billing


This article describes how to set up a chart item for waterfall billing for your Chart Items if the first payer only partially pays or denies. For this to work, both payers have to appear on identical services on the plan goals page. Note that only Admins or for folks with Admin Billing permissions will be able to make any subsequent Claim Item changes.

General ChartItem Setup

  1. Ensure both payers are active with current dates for the client, and with the priorities indicating the order that you want them to bill.
  2. Before approving a chart item for the client make sure both payers are listed at the bottom of the chart item.
  3. The first payer will bill normally, and if it denies or is partially paid then you can use Next Payer to bill the next payer.
  4. Whatever the Due Amount is on the first claim item is the amount that will be billed the second payer, so before you Next Payer you should add a writeoff or adjustment if you want to change the amount billed the second payer.
  5. If everything is working the claim item should show up immediately as a Posted claim item with the intended payer listed on the new claim.

Troubleshooting

Q:  What do I do if a chart item was approved before a second payer was listed at the bottom of the chart item?
A:  To fix this you have to go to each chart item, do Update Payer, and verify that the second payer shows up. Once both payers are listed on the chart item, then Next Payer should work on the claim item. If everything is working correctly then both payers should show up on the client's chart items without you having to always Update Payer.

Q:  OKHCA is always denying. What may fix this problem?
A:  Current understanding is that OKHCA is a payer of "last resort", which means if the client is eligible for another payer you have to bill the other payer first and then OKHCA. If you bill OKHCA first it will always deny. To fix this, set the other payer to be billed first by changing the priority on the client payer to first, and the OKHCA payer priority to second.
  1. See our video Adding a Service Plan for more information on service plans.
  2. More information about working with Plan Goals can be found at Client Treatment Plan Modifications.
  3. For more information on ClaimItem write-offs and adjustments, see our article Manually Reconciling Claim Items.
  4. The Rebilling Claims Due to Client Payer Changes article will have more information for you on the Update Payer action.