Collecting the balance after medical aid pays part
How a practice records a medical scheme, HMO or insurer paying part of a patient's account, tells the patient what is left, and follows the balance up.
By Achekam · · 5 min read · For Healthcare businesses in South Africa, Nigeria, Kenya
The remittance advice arrives from the scheme. For most lines it paid what you charged. For some it paid less: its own tariff was lower than your fee, a co-payment applied, the patient's savings were exhausted, or a procedure code was only partly covered. One or two lines were rejected outright. Every one of those gaps is money the practice is still owed, now by the patient.
Shortfalls are where many practices quietly lose income. The scheme's payment arrives in one lump, the gaps are never turned into a clear balance for each patient, and months later nobody is sure who owes what. This article sets out how to record the scheme's payment properly, tell the patient what is left, follow it up, and decide when a balance is genuinely lost.
Why the account stays part-paid
The visit was invoiced to the patient, or to the main member responsible for the account. Issuing that invoice took the next number in your sequence and posted it to the ledger as debtors, sales and any output VAT, for the full fee. The scheme is paying on the patient's behalf, but the debt is the patient's.
So when the scheme pays less than the fee, the invoice does not quietly shrink. It stays open for the difference, which is exactly what you want: the shortfall remains visible as money owed until someone collects it or a partner decides to write it off.
Recording the scheme's payment against the patient's invoice
Achekam records customer payments against one invoice or spread across a customer's invoices, and a part payment leaves the invoice part-paid. That is the tool for shortfalls. Record what the scheme paid for each patient against that patient's invoice, and the invoice shows as part-paid for the remainder.
A scheme remittance usually covers many patients in one bank deposit. Because a payment is spread across one customer's invoices, not across several customers, split the remittance patient by patient: one receipt for each patient's share, each against that patient's invoices. Keep the remittance advice with the month's records so the split can be checked.
Two cautions:
- Reconciling the bank is not enough. Matching the scheme's deposit to a bank line does not record the payment on any invoice; it must also be recorded in receivables. Skip that and every patient on the remittance keeps receiving reminders for amounts the scheme has already paid.
- Rejected lines are a different conversation. A line rejected for a membership or coding reason may be resubmitted through your claims route. Hold off billing the patient for it until you know whether a resubmission will succeed.
A worked example in words: a scheme's deposit covers three patients. For the first, it paid the whole fee; that receipt clears the invoice. For the second, it paid its tariff, below the practice's fee; that receipt leaves the invoice part-paid for the shortfall. For the third, it rejected a line; the receptionist records what was paid, flags the rejected line for resubmission and waits before billing the patient.
Telling the patient what is still owed
Patients rarely read their scheme's statements closely. A short, clear message from the practice does more than any reminder.
- Send a statement. A customer statement of account is produced as a PDF that can be e-mailed, and the screen says whether it was sent. It shows the original fee, the scheme's payment and the balance in one place.
- Explain the gap. In the covering e-mail, say in plain words why the scheme paid less ("your plan pays its own rate for this procedure, which is below our fee").
- Make it easy to pay. Create a payment link for the invoice and include it. The patient pays on a public page showing the practice's name and branding. A link lasts 14 days by default, and there is no link for a draft or voided invoice.
Following up the balance
From here, the balance follows the same rhythm as any patient account. Credit control is on for new workspaces: once a day it e-mails overdue reminders, by default at 7, 14 and 30 days overdue with the invoice attached, and a monthly statement to every patient with a balance. It never charges anyone, and records whether each e-mail went out.
Remember that Achekam never charges a patient automatically, with no saved cards or debit orders, and that reminder e-mails carry no pay link. If a patient replies to a reminder asking how to pay, send a fresh link from the invoice.
Watch the receivables ageing, which groups balances into 0-30, 31-60, 61-90, 91-120 and over 120 days. Shortfall balances that drift past the second group usually need a phone call. For the day-to-day statement routine itself, see statements and reminders for patient accounts, and for patients who pay by transfer, getting patients to pay with the right EFT reference.
Before deciding a balance cannot be collected
Some shortfalls will not be paid. Before giving up on one, work through a short checklist:
- Was the scheme's payment recorded correctly, and against the right patient?
- Was any rejected line resubmitted, and what came back?
- Did the patient receive at least one statement explaining the gap?
- Has someone spoken to the patient, not just e-mailed?
- Is a payment plan possible?
- Is the patient still visiting, so the balance can be raised at the next appointment?
If the practice decides to reduce the fee itself, for example as a courtesy to a long-standing patient, issue a credit note from the invoice for the chosen amount rather than leaving the balance hanging. If the balance is simply uncollectable, an unpaid debt can be written off once a partner approves, so the decision sits with the partners rather than the front desk. An administrator can void an invoice only when it has no payments or credits, so a part-paid shortfall invoice is closed by a credit note or a write-off, not a void.
In Kenya, the Social Health Authority publishes the benefit tariffs for services under each of its three funds, which helps a practice see in advance where its fees and the fund's tariff will leave a gap for the patient.
A shortfall is a normal part of practice income, not a failure. Record each scheme payment against the right patient, tell the patient clearly what is left, and let the ageing and a partner's decision deal with the few that never come in.
General guidance only, not advice on your own circumstances. Tax and payroll rules change: check the current position with the authority or your adviser.
