AAPC Denial Management & Appeals 3

Question 1

What is the primary goal of tracking a practice's denial rate as a key performance indicator (KPI)?

Accepted Answer

To measure the percentage of claims denied and identify trends to reduce future denials

Answer

To determine how many patients have outstanding balances

Answer

To track the number of new patients seen each month

Answer

To calculate provider productivity

Question 2

Which of the following actions best prevents 'authorization not obtained' denials?

Accepted Answer

Verifying and obtaining prior authorization before services are rendered

Answer

Appealing all such denials after the fact

Answer

Billing a different procedure code that does not require authorization

Answer

Collecting the full payment from the patient upfront

Question 3

A claim is denied because the rendering provider's NPI is not on file with the payer. What should the biller do?

Accepted Answer

Contact the payer to credential/enroll the provider and then resubmit the claim

Answer

Submit the claim without an NPI

Answer

Bill the patient for the full amount

Answer

Adjust off the claim as a write-off

Question 4

What is the significance of tracking the 'days in AR' (accounts receivable) metric in denial management?

Accepted Answer

It measures the average number of days it takes to collect payment after a claim is submitted

Answer

It shows how many days employees work each month

Answer

It calculates the total number of claims submitted annually

Answer

It determines how many denied claims are written off

Question 5

When a payer's remittance advice shows an OA-23 adjustment reason code, what does this mean?

Accepted Answer

The amount is not covered by Medicare; this is a Medicare Secondary Payer situation

Answer

The service was non-covered

Answer

The payment amount has been adjusted based on a payer-initiated reduction

Answer

The claim requires resubmission with additional documentation

Question 6

Which strategy is most effective when a payer continuously denies claims for the same incorrect reason?

Accepted Answer

Document the pattern, escalate to payer relations or a supervisor, and consider a formal complaint if unresolved

Answer

Stop billing that payer

Answer

Accept the denials and write off the balances

Answer

Increase the billed amount to compensate for losses

Question 7

What is a 'crossover claim' in the context of Medicare and Medicaid billing?

Accepted Answer

A claim automatically forwarded from Medicare to Medicaid for additional payment consideration for dual-eligible patients

Answer

A claim submitted to two private insurance companies simultaneously

Answer

A claim denied by Medicare and then sent to the patient

Answer

A claim filed in two different states