CRCR CRCR - Certified Revenue Cycle Representative Program Denial Management and Appeals 5 — Questions and Answers
Question 1: A payer consistently denies claims for a specific high-cost drug citing 'experimental or investigational.' The drug has FDA approval. What is the strongest appeal argument?
- The drug's wholesale acquisition cost is lower than alternatives
- The drug has received full FDA approval and meets evidence-based clinical guidelines for the diagnosis (Correct answer)
- The patient prefers this drug over alternatives
- The provider is an academic medical center
Correct answer: The drug has received full FDA approval and meets evidence-based clinical guidelines for the diagnosis
FDA approval combined with evidence-based guideline support directly refutes an experimental/investigational denial, as approved drugs used on-label cannot be classified as experimental.
Question 2: Which type of denial requires the provider to obtain a signed Advance Beneficiary Notice (ABN) from the patient before billing the patient for the non-covered service?
- Timely filing denial
- Coordination of benefits denial
- Medicare medical necessity denial when the provider believes Medicare will deny (Correct answer)
- Duplicate claim denial
Correct answer: Medicare medical necessity denial when the provider believes Medicare will deny
An ABN must be issued when a provider believes Medicare is likely to deny a service as not medically necessary, allowing the provider to hold the patient liable for the charge if Medicare denies.
Question 3: A revenue cycle team notices that 40% of authorization-related denials are for procedures performed on weekends. What process improvement would best address this pattern?
- Stop scheduling procedures on weekends
- Implement a weekend authorization verification workflow or on-call authorization team (Correct answer)
- Increase clinical documentation requirements for all procedures
- Renegotiate the payer contract to remove prior auth requirements
Correct answer: Implement a weekend authorization verification workflow or on-call authorization team
A dedicated weekend authorization workflow ensures that prior authorizations are verified and obtained even when standard business office staff are unavailable.
Question 4: What is the role of a 'denial reason code crosswalk' in a denial management program?
- It translates ICD-10 codes to CPT codes for billing purposes
- It maps payer-specific denial codes to standardized CARC/RARC codes to facilitate root-cause analysis (Correct answer)
- It converts patient demographic data across different EHR systems
- It matches provider NPI numbers to payer contracts
Correct answer: It maps payer-specific denial codes to standardized CARC/RARC codes to facilitate root-cause analysis
A denial reason code crosswalk standardizes payer-specific denial language to CARC/RARC codes, enabling consistent trend analysis across multiple payers.
Question 5: When calculating the 'cost to collect' on a denied claim, which factor should be weighed against the expected reimbursement to determine whether to pursue an appeal?
- The patient's credit score
- Staff time, appeal fees, and administrative resources required to work the denial (Correct answer)
- The provider's gross revenue for the month
- The payer's star rating with CMS
Correct answer: Staff time, appeal fees, and administrative resources required to work the denial
Weighing appeal costs—staff time, documentation retrieval, and submission effort—against the expected payment helps prioritize which denials are financially worth pursuing.
Question 6: A claim for a surgical procedure is denied because the assistant surgeon's services are not covered per the patient's benefit plan. Which action is appropriate?
- Rebill the assistant surgeon's charges under the primary surgeon's NPI
- Inform the patient of the non-covered benefit and determine if a patient financial responsibility policy applies (Correct answer)
- Write off the assistant surgeon's charges as a contractual adjustment
- Report the denial to the state insurance commissioner as a bad faith practice
Correct answer: Inform the patient of the non-covered benefit and determine if a patient financial responsibility policy applies
When assistant surgeon benefits are excluded from the patient's plan, notifying the patient and reviewing the financial responsibility policy is appropriate before determining the correct billing action.
Question 7: Which of the following best describes the concept of 'global days' in the context of denial management for surgical claims?
- The number of days a payer allows for timely claim filing
- A post-operative period during which follow-up services are included in the surgical procedure payment and billed separately will be denied (Correct answer)
- The maximum number of days a patient can remain hospitalized under a surgical DRG
- The period during which a provider must respond to a payer audit
Correct answer: A post-operative period during which follow-up services are included in the surgical procedure payment and billed separately will be denied
Global days define the post-operative period (0, 10, or 90 days) during which routine follow-up care is bundled into the surgical payment and cannot be billed separately without a modifier.
CRCR CRCR - Certified Revenue Cycle Representative Program Denial Management and Appeals 5
A payer consistently denies claims for a specific high-cost drug citing 'experimental or investigational.' The drug has FDA approval.
What is the strongest appeal argument?