CRCR CRCR - Certified Revenue Cycle Representative Program Insurance Verification and Authorization 2 — Questions and Answers
Question 1: What is the purpose of reviewing an Explanation of Benefits during the insurance verification process?
- To confirm the patient's demographic information
- To understand how a patient's plan pays for specific services and what the patient's cost-sharing responsibilities are (Correct answer)
- To determine the patient's credit score
- To verify the physician's NPI number
Correct answer: To understand how a patient's plan pays for specific services and what the patient's cost-sharing responsibilities are
The EOB outlines plan benefits, coverage limitations, and patient cost-sharing which is essential for accurate financial counseling.
Reviewing an EOB or benefits summary during insurance verification helps revenue cycle staff understand how the patient's plan covers the specific services being provided, including deductible status, copay requirements, coinsurance percentages, and any applicable limitations or exclusions. This information enables accurate financial counseling before care is delivered.
Question 2: A patient's insurance verification reveals a $2,500 deductible with $1,800 already met for the year. What is the patient's remaining deductible exposure?
- $2,500
- $700 (Correct answer)
- $1,800
- $0
Correct answer: $700
The remaining deductible is the difference: $2,500 minus $1,800 equals $700.
The deductible is the amount the patient must pay out-of-pocket before insurance begins covering costs. If the annual deductible is $2,500 and the patient has already met $1,800, the remaining deductible is $700. After that $700 is paid the insurance will begin covering costs according to the plan's coinsurance structure.
Question 3: What does in-network versus out-of-network mean for a patient seeking services?
- In-network means the provider accepts cash only; out-of-network means the provider accepts insurance
- In-network providers have a contracted rate with the patient's insurer resulting in lower cost-sharing; out-of-network providers may cost significantly more (Correct answer)
- In-network services are always covered at 100%; out-of-network services are never covered
- In-network and out-of-network terms only apply to HMO plans
Correct answer: In-network providers have a contracted rate with the patient's insurer resulting in lower cost-sharing; out-of-network providers may cost significantly more
In-network providers have negotiated rates with the insurer which reduces the patient's out-of-pocket costs compared to out-of-network providers.
In-network providers have signed participation contracts with the patient's insurance plan agreeing to accept negotiated rates for services. The insurer covers a higher percentage of in-network costs and the patient pays lower deductibles, copays, and coinsurance. Out-of-network providers have no contract so the patient typically pays a higher share of costs.
Question 4: Which information is typically required when calling a payer to verify insurance eligibility?
- The patient's credit card number and billing address
- The patient's name, date of birth, insurance ID number, and the provider's NPI (Correct answer)
- The patient's prior authorization number and claim history
- The patient's primary care physician's license number
Correct answer: The patient's name, date of birth, insurance ID number, and the provider's NPI
Payers use the patient's demographics, insurance ID, and provider NPI to look up and verify coverage.
To verify insurance eligibility by phone staff typically need the patient's full name, date of birth, insurance member ID number, group number if applicable, and the rendering provider's NPI. The payer uses this information to locate the policy and confirm active coverage, deductible status, and copay or coinsurance obligations.
Question 5: What is the consequence of billing a service that required prior authorization but for which authorization was not obtained?
- The claim will be paid at the standard rate
- The claim will typically be denied and the provider may be responsible for writing off the balance (Correct answer)
- The patient automatically owes the full billed charge
- The claim will be paid after the deductible is met
Correct answer: The claim will typically be denied and the provider may be responsible for writing off the balance
Most payers require prior authorization for specific services and failure to obtain it results in a claim denial that the provider generally cannot bill to the patient.
When a service requires prior authorization and it is not obtained the payer will typically deny the claim. In most cases if the patient was not notified that authorization was required and not obtained the provider cannot collect the balance from the patient. The result is that the provider must write off the charge.
Question 6: What is concurrent review in the context of utilization management and prior authorization?
- A review of claims after discharge to determine if the admission was appropriate
- A review conducted during an inpatient stay to determine if continued hospitalization is medically necessary (Correct answer)
- A review of the patient's financial capacity before admission
- A comparison of two different insurance plans for coverage purposes
Correct answer: A review conducted during an inpatient stay to determine if continued hospitalization is medically necessary
Concurrent review is the ongoing clinical review by a payer to determine whether continued inpatient care remains medically necessary.
Concurrent review is a utilization management process in which the payer's clinical reviewers evaluate the medical necessity of continued inpatient hospitalization during the patient's stay. Case managers at the hospital must proactively communicate clinical information to support continued day authorizations. Failure to obtain continued authorization can result in denial of inpatient days.
CRCR CRCR - Certified Revenue Cycle Representative Program Insurance Verification and Authorization 2
What is the purpose of reviewing an Explanation of Benefits during the insurance verification process?