1 0 Hidden Insurance Lt Bckgd
Insurance Coverage Discrepancies – Hidden Insurance/Payer

Difficulty: Moderate  //  Patient Financial Services

Why run this play?

By reallocating incorrectly classified self-pay accounts to the patient guarantor’s appropriate payer (whether Medicaid or other insurance backed payers) you can reduce bad debt expense and achieve improved reimbursement and A/R liquidity.


When you continuously identify and monitor patients/guarantors who were potentially misstated as self-pay, you ensure the correct payers are being billed and reduce unnecessary re-work. This helps you expedite insurance updates and resubmit claims to the correct carriers. For similar dates of service, patients/guarantors should typically have the same insurance on file. We have found that roughly 2 to 5% of our clients’ self-pay dollars are triggered for investigation for this play.

Take Action

  1. Isolate all your self-pay patients.
  2. Join your self-pay patients to the full ATB dataset and find any matches on MRN (or unique identifier) where the primary insurance <> self-pay within a similar time period.
  3. Verify payer eligibility on all qualifying accounts and re-submit misclassified self-pay accounts to the appropriate payer.
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How to Calculate This Play's Value

  1. Identify the date the account was flagged with a potential hidden insurance issue.
  2. Sum all insurance payments where the payment posted date is > identification date.

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