CRCR Account Follow-Up and Collections 5 — Questions and Answers
Question 1: When a commercial payer denies a claim as 'not covered,' which of the following should be reviewed FIRST?
- The patient's payment history
- The payer's Explanation of Benefits and the provider's contract to determine coverage scope (Correct answer)
- The hospital's chargemaster
- The patient's credit score
Correct answer: The payer's Explanation of Benefits and the provider's contract to determine coverage scope
Reviewing the EOB alongside the payer contract clarifies whether the service should in fact be covered and whether an appeal is warranted.
Question 2: Which of the following best describes a 'soft' credit inquiry versus a 'hard' credit inquiry in the context of patient collections?
- Soft inquiries are used for pre-service eligibility; hard inquiries are for insurance verification
- Soft inquiries do not affect a patient's credit score; hard inquiries may impact it (Correct answer)
- Soft inquiries are only used for Medicare patients; hard inquiries apply to commercial payers
- Soft inquiries require patient consent; hard inquiries do not
Correct answer: Soft inquiries do not affect a patient's credit score; hard inquiries may impact it
In patient collections, propensity-to-pay tools may use soft inquiries, which don't affect credit scores, unlike hard inquiries from formal credit checks.
Question 3: A claim is denied because the rendering provider's NPI is not enrolled with the payer. What is the most effective resolution?
- Recode the claim under a different provider's NPI
- Enroll the provider with the payer and resubmit once credentialing is confirmed (Correct answer)
- Write off the claim and bill the patient
- Submit a corrected claim with the facility NPI only
Correct answer: Enroll the provider with the payer and resubmit once credentialing is confirmed
Completing payer enrollment and credentialing for the rendering provider and resubmitting is the correct resolution for NPI-related denials.
Question 4: Which approach is considered a best practice for reducing bad debt in a hospital's self-pay accounts?
- Sending accounts to collections immediately after discharge
- Screening patients for charity care eligibility and offering payment plans proactively (Correct answer)
- Requiring full payment before providing non-emergency services
- Writing off all balances under $50 without follow-up
Correct answer: Screening patients for charity care eligibility and offering payment plans proactively
Early identification of charity care candidates and proactive payment plan offers reduces bad debt and improves patient relations.
Question 5: What does the term 'appeal level' refer to in the payer denial management process?
- The number of claims submitted in a billing cycle
- The sequential stages of the formal appeals process available to contest a denial (Correct answer)
- The dollar threshold for writing off a balance
- The hierarchy of payers in a COB situation
Correct answer: The sequential stages of the formal appeals process available to contest a denial
Appeal levels refer to the ordered stages (first-level, second-level, external review) through which a provider can formally contest a denial.
Question 6: A revenue cycle department notices that 20% of claims from a specific payer are being denied for 'lack of prior authorization.' What is the best systemic fix?
- Accept the denial rate as normal for that payer
- Implement a pre-service authorization workflow that captures authorizations before services are rendered (Correct answer)
- Bill all patients directly for that payer's services
- Terminate the contract with the payer
Correct answer: Implement a pre-service authorization workflow that captures authorizations before services are rendered
A pre-service authorization workflow prevents prior authorization denials by ensuring approvals are obtained before care is delivered.
Question 7: Which statement accurately describes the difference between a 'rejection' and a 'denial' in claims processing?
- Rejections occur after a claim is adjudicated; denials occur before
- Rejections occur before adjudication due to errors; denials occur after adjudication based on payer determination (Correct answer)
- Rejections require an appeal; denials can be corrected and resubmitted
- There is no meaningful difference between a rejection and a denial
Correct answer: Rejections occur before adjudication due to errors; denials occur after adjudication based on payer determination
Rejections are identified before the claim enters adjudication and require correction and resubmission; denials result from the payer's coverage or policy decision after review.
CRCR Account Follow-Up and Collections 5
When a commercial payer denies a claim as 'not covered,' which of the following should be reviewed FIRST?