Balances & Deductibles
Every insurance session has two potential payers: the insurance company and the client. Getting the split right — up front and after adjudication — is most of what "insurance billing hygiene" means.
The Three-Part Split
For each session, the fee resolves into:
- Insurance pays — the payer's share of the allowed amount
- Client pays — copay, coinsurance, or deductible amounts
- Adjustment — the contractual write-off between your billed fee and the allowed amount (nobody pays this)
Estimating Client Responsibility Up Front
Set the client's expected per-session amount in the coverage's single Copay/Coinsurance field — a dollar figure ("For coinsurance, enter the calculated dollar amount") on their coverage. The estimate seeds each session's client responsibility, so you can collect at time of service and the client isn't surprised months later.
Coinsurance is genuinely an estimate — the true amount depends on the payer's allowed amount. Recording your contracted rates makes the estimate accurate; the ERA trues it up.
Deductibles
Until a client meets their deductible, payers process claims but pay $0 — the full allowed amount becomes client responsibility. Those claims come back with the Deductible status.
What to do:
- Still file the claim. Deductible-phase claims are how the payer counts the client's spending toward the deductible — skipping them stalls the client's progress to coverage
- Bill the client for the allowed amount (not your full fee — the contractual adjustment still applies if you're in-network)
- Early in the calendar year, expect more Deductible statuses; collecting a realistic estimate at time of service avoids big catch-up invoices
After the ERA
When the ERA posts, the real split replaces the estimate: the client's remaining responsibility lands on their billing like any other balance, ready to invoice or AutoPay.