Patient responsibility

Patient responsibility is what the payer says the patient owes. After the payer sets the allowed amount, it splits that figure between itself and the patient according to the plan’s benefits. The patient’s share arrives on the ERA or EOB under the PR (patient responsibility) group code, with a reason code for each piece: X12 lists CARC 1 as the deductible amount, CARC 2 as the coinsurance amount and CARC 3 as the copayment amount. Non-covered services the patient agreed to pay for can also appear under PR.

The group code decides who gets a bill. A CO adjustment is written off; a PR adjustment is transferred to the patient’s account and billed, or applied to a copay already collected at the visit. Because the same dollar cannot be both, payment posting has to read the group code, not just the amount. If a secondary plan exists, the PR amounts from the primary are what the secondary claim asks it to cover, so they have to be posted exactly before the secondary goes out.

The mistake is billing the patient for the wrong thing. Charges above the allowed amount sent to an in-network patient, a denial for a provider error billed as if it were patient responsibility, or a deductible billed before the secondary payer has been given a chance all generate complaints and refunds. Bill only what arrived under PR, after every payer has adjudicated, and show the patient the same amounts they see on their EOB.