Automatic, pain-free EOB and claim reconciliation

In the complex world of healthcare reimbursement, discrepancies between open claims and explanation of benefits can lead to massive revenue losses if not carefully watched. This clinic, like many, dealt with the risk by assigning more people to it: eight full-time staffers (with two open positions) spent their days manually reviewing 4,200+ EOB documents each month — a mix of paper and electronic images — and checking amounts against open claims from the clinic’s billing software to ensure the net payment matched the expected billing amount. EOB documents often included multiple patient ICN codes that needed to be extracted as individual line items. At best, this manual reconciliation took 8 days and the team was stretched.

FormedAI now electronically processes all EOBs with outsourced data capture (with guaranteed 99% data accuracy and a four-hour turnaround). Each line item is extracted and a digital workflow checks the billing system to match the amount received with the balance. Since most EOBs underpay the claim, FormedAI developed a table of automated rules that lets the system compare allowed deductions per each insurance plan and then determine whether to accept the amount received based on those rules, or route the exception to a specialist for additional review. Amounts are then imported into billing software to automatically bill patients on open balances.