Contractual Adjustments vs. Balance Billing: The Golden Rule of In-Network Care

Ever looked at a payment from an insurance company and felt like you were reading a math problem designed to make you lose?

You bill $180 for a session. The insurance company sends back a statement saying the “Allowed Amount” is $112.50. Then, they send you a check for $90 because the patient has a $22.50 copay.

Suddenly, there is a $67.50 difference sitting on your ledger. For many providers, that number is a source of major frustration—it feels like money that is rightfully yours is simply vanishing.

At Practice Solutions, we call this the "friction point" of Revenue Cycle Management. Understanding the difference between a Contractual Adjustment and Balance Billing is the "Golden Rule" of taking insurance. It’s the difference between a clean, ethical practice and a massive compliance headache.

Defining the Contractual Adjustment (The "Write-Off")

In the billing world, we use the term Contractual Adjustment (often labeled as a CO or Contractual Obligation on your EOB).

This isn't just an accounting term; it’s a legal one. When you signed your contract to become an In-Network Provider, you agreed to a specific Fee Schedule. By doing so, you essentially told the insurance company, "I am willing to accept $112.50 as the total payment for this service, even though my standard rate is $180."

Think of it like a "Club Member Price." If you go to a big-box retailer, you get the member discount because of the agreement in place. As a provider, the "member discount" is what you give the insurance company in exchange for them sending their members to your practice.

The $67.50 difference in our example? That’s the adjustment. You must "write it off" in your EHR. It isn't a debt the patient owes you; it’s the cost of doing business within that network.

The Danger Zone: What is Balance Billing?

This is where things get tricky—and where some practices get into hot water.

Balance Billing is the practice of billing the patient for the difference between your billed amount ($180) and the insurance company’s allowed amount ($112.50).

In our scenario, if you sent a bill to the patient for that $67.50 adjustment, you would be balance billing.

Here is the hard truth: If you are in-network, balance billing is almost always a violation of your provider contract. It’s one of the fastest ways to get flagged for an audit or even kicked out of an insurance network. Payer contracts are designed to protect the patient from "surprise" costs, and they take these protections very seriously.

Why Accuracy in Payment Posting Matters

To win at "The Claim Game," your bookkeeping must reflect reality. If you don't post those contractual adjustments correctly, your "Aging Report" (the list of who owes you money) will be a total mess.

You’ll see thousands of dollars in "Patient Responsibility" that isn't actually real. This creates a "Frankenstein’s monster" of a ledger that makes it impossible to know the actual financial health of your practice.

When you (or your biller) post a payment, you must ensure that:

1. The Allowed Amount is identified.

2. The Patient Responsibility (Copay/Coinsurance) is billed to the patient.

3. The Contractual Adjustment is written off immediately.

Focus on the "Big Bucket"

We know it can feel discouraging to see those write-offs. But remember: every provider is capable of running a successful, profitable practice while honoring these contracts. The key is making sure your "billed amount" is high enough to always capture the full allowed amount (we recommend setting your fees at 150-200% of the Medicare rate) so you never cap your own revenue.

By mastering these definitions, you move from feeling like a victim of the insurance system to being a savvy business owner in control of your revenue cycle.

Follow-Up Actions to Take:

• [ ] Audit your Ledger: Look at your current Aging Report. Do you see "balances" for patients that are actually un-posted contractual adjustments?

• [ ] Review your Fee Schedule: Ensure your billed rates are high enough that you aren't accidentally billing less than what the insurance is willing to pay you.

• [ ] Train your Team: Ensure whoever is posting payments in your EHR knows the difference between a "Patient Balance" and a "Contractual Obligation."

Do you have questions about how to read your specific EOBs? We want to help you create clarity in your practice. Reach out to our team at Practice Solutions today!