CRCR CRCR - Certified Revenue Cycle Representative Program Denial Management and Appeals 4 — Questions and Answers
Question 1: What is the primary purpose of a Peer-to-Peer (P2P) review in the denial management process?
- To negotiate a discounted contractual rate with the payer
- To allow the treating physician to discuss the clinical case directly with the payer's medical reviewer (Correct answer)
- To request a refund of an overpayment
- To escalate a billing dispute to the state insurance department
Correct answer: To allow the treating physician to discuss the clinical case directly with the payer's medical reviewer
A P2P review gives the treating physician the opportunity to present clinical rationale directly to the payer's physician reviewer, often reversing medical necessity denials before a formal appeal.
Question 2: A claim denied for 'lack of prior authorization' is later discovered to have had authorization obtained but the wrong auth number was entered. What is the best resolution path?
- Write off the claim as uncollectible
- File an appeal with proof of the valid authorization number and confirmation from the payer (Correct answer)
- Rebill the claim with the same incorrect auth number
- Ask the patient to pay and then appeal for reimbursement
Correct answer: File an appeal with proof of the valid authorization number and confirmation from the payer
Submitting an appeal that includes documented proof of the valid prior authorization demonstrates that authorization was secured and the denial was due to a data entry error.
Question 3: Which metric best measures the effectiveness of a denial prevention program over time?
- Total gross charges submitted per month
- Denial rate as a percentage of claims submitted (Correct answer)
- Number of patient complaints filed
- Average length of patient stay
Correct answer: Denial rate as a percentage of claims submitted
Tracking denial rate as a percentage of total claims submitted provides a normalized, trend-able measure of how well prevention efforts are reducing initial denials.
Question 4: An appeal letter for a medical necessity denial should always include which of the following?
- A copy of the provider's malpractice insurance certificate
- Patient-specific clinical documentation supporting the necessity of the service (Correct answer)
- The provider's tax identification number only
- A demand for arbitration
Correct answer: Patient-specific clinical documentation supporting the necessity of the service
Patient-specific clinical documentation—such as progress notes, lab results, and physician orders—directly addresses the payer's medical necessity criteria and is the foundation of a strong appeal.
Question 5: When a payer denies a claim as 'out of network' but the provider holds a valid contract, what is the first step in the resolution process?
- Immediately file a complaint with CMS
- Verify the credentialing and contract effective dates with the payer's provider relations department (Correct answer)
- Balance bill the patient for the full amount
- Terminate the payer contract
Correct answer: Verify the credentialing and contract effective dates with the payer's provider relations department
Contacting provider relations to confirm that the provider's credentialing is active and the contract dates are correctly loaded addresses the root cause of most erroneous out-of-network denials.
Question 6: A hospital's denial management dashboard shows a spike in 'bundling' denials for cardiac catheterization cases. What is the most likely root cause?
- The payer's fee schedule was updated and rates decreased
- Component billing of procedures that are included in the global catheterization code (Correct answer)
- The patients' deductibles were not collected at time of service
- The claims were submitted past the timely filing deadline
Correct answer: Component billing of procedures that are included in the global catheterization code
Bundling denials for cardiac catheterization typically result from billing ancillary components such as radiological supervision separately when they are already included in the comprehensive procedure code.
Question 7: Under ERISA, a self-funded plan must provide a written notice of benefit denial within how many days for a non-urgent post-service claim?
- 30 days
- 60 days (Correct answer)
- 90 days
- 180 days
Correct answer: 60 days
ERISA regulations require ERISA-governed plans to furnish a written denial notice for post-service claims within 60 days of receiving the claim.
CRCR CRCR - Certified Revenue Cycle Representative Program Denial Management and Appeals 4
What is the primary purpose of a Peer-to-Peer (P2P) review in the denial management process?