Pro-Rated Hours and Overbilling

In Theralytics, the automated authorization tracking feature acts as a vital guardrail, specifically designed to protect your practice from overbilling. When an insurance company approves a weekly or monthly block of hours right in the middle of a calendar cycle, they may expect those initial hours to be prorated to match the fraction of time remaining. This software feature exists for a very good reason: it stops you from accidentally "cramming" a full week or month's worth of therapy into a smaller window, effectively preventing claim denials for over-utilization before they happen. 

The Pro-Rate Feature

Insurance companies may not grant you a pass to use a full week or month's worth of hours if you only have a fraction of that time left to provide services. In order to help prevent overbilling, the Authorizations feature in Theralytics treats weekly and monthly auths differently.

• Weekly Authorizations: If a client is authorized for 21 hours per week, but the authorization starts on a Thursday, you only have Thursday, Friday, Saturday and Sunday left in the week. If you attempt to bill all 21 hours in those four days, Theralytics will say you only have 12 hours remaining.

• The Monthly View: If a monthly authorization for 60 hours starts on the 20th of the month, trying to fit all 60 hours into the remaining 10 days means billing 6 hours a day, every single day. Theralytics will prevent you from doing this as well.

The Risk: Many insurance payers expect you to prorate the hours for that first partial cycle. If you bill the full amount, their automated systems may flag it as over-utilization or clinically impossible, potentially leading to a denial.

How are weeks/months calculated?

Here is how the weekly and monthly time frames are calculated in Theralytics:

• Weeks are almost always calculated from Sunday to Saturday

• Months are the 1st through the 30th/31st

If a weekly or monthly auth starts in the middle of the week or month, the system doesn't create a custom auth period for you. It evaluates that as a standalone, partial period and allows you only to schedule a certain amount of the remaining auth for that month. The next month or week you will have access to the full amount.

There are ways around this. You can either:

1. Set the start date of the auth to the Sunday of that week or the 1st of the month.

2. Contact our team at support@theralytics.net to turn off the pro rate feature for your database.

Areas to Consider

Even if a claim somehow slips through an automated system and gets paid, "cramming" units into a short window can be flagged by the end user.

If the documentation doesn't perfectly justify why the client suddenly received double the normal daily therapy, the insurance company may initiate a clawback—meaning they take the money back months after you've already spent it. Please review your payer guidelines for additional information.

As a good rule of thumb when starting mid-cycle:

• Calculate the daily average: Use the client’s authorization page and divide the total weekly/monthly authorized hours by the standard number of days in that cycle to see what a "normal" day looks like.

• Only bill what was actually worked: Match the schedule to the clinical reality of those few remaining days.