CRCR CRCR - Certified Revenue Cycle Representative Program Account Follow-Up and Collections 4 — Questions and Answers
Question 1: A claim is denied because the patient's insurance coverage was terminated on the date of service. What is the best course of action?
- Write off the balance as a bad debt
- Verify eligibility retroactively, identify any active coverage, and re-bill or move to self-pay accordingly (Correct answer)
- Immediately send the balance to external collections
- Appeal the denial without additional information
Correct answer: Verify eligibility retroactively, identify any active coverage, and re-bill or move to self-pay accordingly
When coverage is denied due to termination, staff should retroactively verify eligibility, check for other active insurance, and either re-bill the correct payer or convert to self-pay.
Question 2: Which of the following best describes a 'hardship write-off' in the context of healthcare collections?
- A write-off triggered when a payer fails to respond within the timely filing limit
- A reduction or elimination of patient balance based on demonstrated financial inability to pay (Correct answer)
- A contractual adjustment required by a payer's fee schedule
- A write-off applied automatically after 180 days of non-payment
Correct answer: A reduction or elimination of patient balance based on demonstrated financial inability to pay
A hardship write-off is granted when a patient demonstrates documented financial inability to pay, often after completing a financial assistance application.
Question 3: What is the primary risk of placing an account with an external collection agency without first exhausting internal collection efforts?
- The agency may negotiate a higher settlement
- The patient relationship may be unnecessarily damaged and revenue may be lost to agency fees (Correct answer)
- The payer may reprocess the claim automatically
- The account may be re-aged, resetting the timely filing clock
Correct answer: The patient relationship may be unnecessarily damaged and revenue may be lost to agency fees
Premature placement with an external agency damages patient relationships and reduces net recovery because agencies retain a percentage of collected amounts.
Question 4: Under HIPAA, which information may a healthcare organization share with a collection agency working on its behalf?
- Only the patient's name and date of birth
- The minimum necessary protected health information (PHI) required to perform the collection activity (Correct answer)
- No PHI — only billing codes and amounts
- Full medical records without restriction
Correct answer: The minimum necessary protected health information (PHI) required to perform the collection activity
HIPAA's minimum necessary standard permits sharing only the PHI required for the collection agency to perform its function as a business associate.
Question 5: A payer issues a recoupment notice stating it will offset future payments to recover an overpayment made 18 months ago. What should the revenue cycle team do first?
- Accept the recoupment and process the offset immediately
- Review the original claim and remittance to determine if the overpayment is valid before accepting or disputing (Correct answer)
- Refund the amount directly without reviewing the claim
- Ignore the notice until the offset appears on a remittance
Correct answer: Review the original claim and remittance to determine if the overpayment is valid before accepting or disputing
Before accepting a recoupment, the team should audit the original claim and remittance to confirm whether the overpayment actually occurred and whether the amount is correct.
Question 6: Which federal law governs the collection practices of third-party debt collectors pursuing patient balances on behalf of healthcare providers?
- Health Insurance Portability and Accountability Act (HIPAA)
- Fair Debt Collection Practices Act (FDCPA) (Correct answer)
- Emergency Medical Treatment and Labor Act (EMTALA)
- Consolidated Omnibus Budget Reconciliation Act (COBRA)
Correct answer: Fair Debt Collection Practices Act (FDCPA)
The FDCPA regulates third-party collectors' conduct, including prohibitions on harassment, false statements, and unfair practices when collecting consumer debts.
Question 7: What does a 'clean claim rate' measure in the context of accounts receivable management?
- The percentage of patients who pay before their first statement
- The percentage of claims submitted that are accepted and paid on the first submission without rejection or denial (Correct answer)
- The ratio of charity care write-offs to gross charges
- The number of claims processed within 30 days of service
Correct answer: The percentage of claims submitted that are accepted and paid on the first submission without rejection or denial
Clean claim rate measures the proportion of claims paid on first submission, reflecting billing accuracy and the efficiency of the revenue cycle.
CRCR CRCR - Certified Revenue Cycle Representative Program Account Follow-Up and Collections 4
A claim is denied because the patient's insurance coverage was terminated on the date of service.
What is the best course of action?