Financial Processes Flashcards

A patient has both Medicare and a commercial secondary insurance. In what order should claims be processed?

Answer: Medicare first as primary, then commercial secondary

Medicare coordination of benefits rules establish Medicare as primary when the patient has Medicare plus a commercial plan (with specific exceptions for employer group health plans).

What is the difference between a copay and coinsurance?

Answer: A copay is a fixed dollar amount; coinsurance is a percentage of the allowed amount

A copay is a set fee per service (e.g., $30), while coinsurance is a percentage of the approved amount the patient pays after meeting their deductible.

A self-pay patient cannot afford their estimated bill. What financial assistance options should the access associate discuss?

Answer: Payment plans, sliding fee scales, charity care applications, and Medicaid eligibility screening

A comprehensive financial counseling approach includes multiple options to help patients access care while meeting their financial obligations.

What is the purpose of an Explanation of Benefits (EOB)?

Answer: To explain how the insurance company processed a claim, including what was paid and what the patient owes

An EOB details how a claim was adjudicated, showing allowed amounts, insurance payments, adjustments, and patient responsibility.

Which federal program provides coverage for patients with End-Stage Renal Disease (ESRD) regardless of age?

Answer: Medicare

Medicare covers patients with ESRD regardless of age, making it a special eligibility category outside the typical age-65 requirement.

What is the financial impact of failing to verify insurance eligibility before a patient's visit?

Answer: Potential claim denials, delayed payments, and increased patient bad debt

Unverified eligibility leads to claim denials, rework costs, delayed revenue, and potential inability to collect from patients.