CRCR Account Follow-Up and Collections 4 — Questions and Answers
Question 1: A patient's claim was denied because coverage was terminated before the date of service. What is the best next step?
- Write off the balance
- Verify coverage dates and, if coverage existed, provide proof of eligibility to the payer (Correct answer)
- Recode the claim with a different diagnosis
- Submit the claim to the secondary payer immediately
Correct answer: Verify coverage dates and, if coverage existed, provide proof of eligibility to the payer
Confirming the patient's actual coverage period and submitting proof to the payer can overturn an eligibility-related denial.
Question 2: What is the significance of the 'timely filing limit' in claims follow-up?
- It determines when the patient's deductible resets
- It is the deadline by which a claim must be submitted to a payer for consideration (Correct answer)
- It defines how long a provider can collect from a patient
- It governs when Medicare secondary payer rules apply
Correct answer: It is the deadline by which a claim must be submitted to a payer for consideration
Missing the timely filing limit results in a non-appealable denial, making it critical to monitor submission deadlines by payer.
Question 3: Which metric measures the average number of days it takes a practice to collect revenue after a service is provided?
- Denial rate
- Cost to collect
- Days in accounts receivable (AR) (Correct answer)
- Net collection rate
Correct answer: Days in accounts receivable (AR)
Days in AR measures the average time between service delivery and payment receipt, indicating collection efficiency.
Question 4: A payer denies a claim stating the procedure requires a referral that was not obtained. Which step best resolves this?
- Accept the denial and write off the balance
- Retroactively obtain the referral from the primary care physician if allowed by the payer (Correct answer)
- Refile under a different insurance plan
- Send the account to a collection agency
Correct answer: Retroactively obtain the referral from the primary care physician if allowed by the payer
Some payers allow retroactive referrals; obtaining one and submitting an appeal may reverse the denial.
Question 5: What is the primary goal of a 'root cause analysis' performed on denied claims?
- To calculate the contractual adjustment amount
- To identify patterns that cause denials and implement process improvements (Correct answer)
- To determine the correct billing code
- To communicate with patients about balances
Correct answer: To identify patterns that cause denials and implement process improvements
Root cause analysis helps identify systemic issues leading to repeated denials so corrective actions can reduce future revenue loss.
Question 6: Under HIPAA, what must a provider do before sharing a patient's billing information with a third-party collection agency?
- Obtain written consent from the patient each time
- Ensure the agency has a Business Associate Agreement (BAA) in place (Correct answer)
- Submit the information only via fax
- Notify CMS before transferring the account
Correct answer: Ensure the agency has a Business Associate Agreement (BAA) in place
A Business Associate Agreement is required under HIPAA when PHI is shared with external vendors like collection agencies.
Question 7: Which follow-up action is most appropriate when a claim has been pending with a payer for 45 days without a response?
- Write off the claim as uncollectable
- Contact the payer to check claim status and document the interaction (Correct answer)
- Immediately file a formal complaint with the state insurance commissioner
- Bill the patient for the full billed amount
Correct answer: Contact the payer to check claim status and document the interaction
Proactively contacting the payer and documenting the inquiry maintains claim momentum and creates a follow-up record.
CRCR Account Follow-Up and Collections 4
A patient's claim was denied because coverage was terminated before the date of service.
What is the best next step?