CRCR - Certified Revenue Cycle Representative Program Account Follow-Up and Collections Flashcards

When a payer denies a claim as 'not medically necessary,' what is the most appropriate first step in the appeals process?

Answer: Obtain clinical documentation supporting medical necessity and submit a formal appeal

A 'not medically necessary' denial requires gathering clinical documentation that demonstrates the medical necessity of the service before submitting a formal appeal.

Under the Fair Debt Collection Practices Act (FDCPA), how soon must a debt collector send a written validation notice after initial contact with a debtor?

Answer: Within 5 days

The FDCPA requires debt collectors to send a written validation notice within 5 days of initial contact with the debtor.

A patient's account is 120 days past due and the guarantor has not responded to multiple statements. Which collection strategy is most appropriate next?

Answer: Escalate to a phone call or place the account in a collection work queue

At 120 days past due with no response to statements, escalating to direct phone contact or a collections work queue is the appropriate next step before external placement.

Which term describes the process of reviewing aged accounts receivable to identify and prioritize those requiring follow-up?

Answer: Accounts receivable (A/R) aging analysis

A/R aging analysis categorizes outstanding balances by the length of time they have been unpaid, enabling prioritization of follow-up efforts.

A payer's electronic remittance advice (ERA) shows a claim was paid at a lower rate than expected. What should the revenue cycle representative do first?

Answer: Compare the paid amount against the negotiated fee schedule to identify a contractual discrepancy

Comparing the ERA payment to the contracted fee schedule reveals whether the payer has underpaid relative to the negotiated rate, which may warrant a contractual dispute.

What is the purpose of a 'demand letter' in the healthcare collections process?

Answer: To formally request payment from a patient or guarantor and outline consequences for non-payment

A demand letter formally notifies the guarantor that payment is required and may describe next steps such as credit reporting or referral to collections.

Which metric best measures the effectiveness of a healthcare organization's collections efforts over time?

Answer: Days in accounts receivable (Days in A/R)

Days in A/R measures the average number of days it takes to collect outstanding revenue, making it a key indicator of collections efficiency.