CRCR CRCR - Certified Revenue Cycle Representative Program Account Follow-Up and Collections 3 — Questions and Answers
Question 1: When a payer denies a claim as 'not medically necessary,' what is the most appropriate first step in the appeals process?
- Write off the balance immediately
- Obtain clinical documentation supporting medical necessity and submit a formal appeal (Correct answer)
- Bill the patient for the full amount without further review
- Re-submit the claim with the same information
Correct 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.
Question 2: 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?
- Within 30 days
- Within 5 days (Correct answer)
- Within 10 days
- Within 60 days
Correct answer: Within 5 days
The FDCPA requires debt collectors to send a written validation notice within 5 days of initial contact with the debtor.
Question 3: 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?
- Send the account directly to external collections without further contact
- Make a courtesy adjustment and close the account
- Escalate to a phone call or place the account in a collection work queue (Correct answer)
- Issue a final statement and wait another 60 days
Correct 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.
Question 4: Which term describes the process of reviewing aged accounts receivable to identify and prioritize those requiring follow-up?
- Claim scrubbing
- Accounts receivable (A/R) aging analysis (Correct answer)
- Remittance reconciliation
- Charge capture auditing
Correct 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.
Question 5: 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?
- Accept the payment and adjust off the difference
- Compare the paid amount against the negotiated fee schedule to identify a contractual discrepancy (Correct answer)
- Re-bill the claim at a higher charge
- Contact the patient to collect the underpayment
Correct 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.
Question 6: What is the purpose of a 'demand letter' in the healthcare collections process?
- To notify a payer of a coding change
- To formally request payment from a patient or guarantor and outline consequences for non-payment (Correct answer)
- To appeal a clinical denial with the payer's medical director
- To authorize a payment plan for a self-pay patient
Correct 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.
Question 7: Which metric best measures the effectiveness of a healthcare organization's collections efforts over time?
- Gross charges per discharge
- Days in accounts receivable (Days in A/R) (Correct answer)
- Number of new patient registrations
- Average length of stay
Correct 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.
CRCR CRCR - Certified Revenue Cycle Representative Program Account Follow-Up and Collections 3
When a payer denies a claim as 'not medically necessary,' what is the most appropriate first step in the appeals process?