CRCR CRCR - Certified Revenue Cycle Representative Program Insurance Verification and Authorization 4 ā Questions and Answers
Question 1: A patient scheduled for an inpatient admission has Medicare as primary and Medicaid as secondary. The hospital verifies Medicare eligibility but skips Medicaid verification. What risk does this create?
- No risk, since Medicaid always pays whatever Medicare does not
- The hospital may miss cost-sharing amounts Medicaid would cover, leaving a balance the patient cannot afford (Correct answer)
- Medicare will deny the claim if Medicaid is not billed simultaneously
- The hospital is legally prohibited from billing Medicaid without prior authorization
Correct answer: The hospital may miss cost-sharing amounts Medicaid would cover, leaving a balance the patient cannot afford
Failing to verify Medicaid eligibility may result in the provider not billing Medicaid for cost-sharing, leaving the patient with a balance they are often legally protected from owing.
Question 2: An authorization number is obtained for a colonoscopy coded as a screening procedure. The physician finds and removes a polyp, changing the code to a therapeutic procedure. What should the revenue cycle team do?
- Bill with the original screening code to match the authorization
- Contact the payer to update or obtain a new authorization for the changed procedure code (Correct answer)
- Submit the claim without an authorization since the change was medically necessary
- Downcode the claim to match the original authorization
Correct answer: Contact the payer to update or obtain a new authorization for the changed procedure code
When the procedure code changes materially, the payer must be notified and a new or amended authorization obtained to avoid denial.
Question 3: Which verification element confirms that the specific provider or facility is contracted with the patient's insurance plan?
- Eligibility verification
- Network/participation status verification (Correct answer)
- Benefits verification
- Coordination of benefits verification
Correct answer: Network/participation status verification
Network or participation status verification confirms whether the provider is in-network with the patient's plan, affecting the benefit level the patient receives.
Question 4: A payer denies a claim stating 'authorization not obtained.' The revenue cycle team confirms they received a verbal authorization. What is the best course of action?
- Write off the balance since verbal authorizations are not valid
- Appeal with documentation of the verbal authorization, including date, time, and representative name (Correct answer)
- Rebill the claim with a different procedure code
- Balance bill the patient for the full amount
Correct answer: Appeal with documentation of the verbal authorization, including date, time, and representative name
Verbal authorizations, when properly documented with the reference number and representative information, can support an appeal of a denial.
Question 5: What is the primary purpose of obtaining a patient's insurance ID card at registration?
- To calculate the patient's copay before the visit
- To verify the member ID, group number, and payer contact information needed for eligibility checks (Correct answer)
- To determine whether the patient qualifies for financial assistance
- To confirm the patient's primary care physician
Correct answer: To verify the member ID, group number, and payer contact information needed for eligibility checks
The insurance ID card provides key identifiersāmember ID, group number, and payer phone/portal informationārequired to conduct an accurate eligibility verification.
Question 6: A self-funded employer plan denies a prior authorization request. Under ERISA, the plan is governed by federal law. Which entity has regulatory authority over self-funded plan authorization denials?
- State Department of Insurance
- U.S. Department of Labor (DOL) (Correct answer)
- Centers for Medicare & Medicaid Services (CMS)
- State Attorney General's office
Correct answer: U.S. Department of Labor (DOL)
Self-funded employer plans are governed by ERISA and regulated by the U.S. Department of Labor, not state insurance regulators.
Question 7: When verifying benefits for a patient with a high-deductible health plan (HDHP) paired with an HSA, what is a key financial counseling point the revenue cycle staff should communicate?
- The patient has no out-of-pocket responsibility until the deductible is fully met by the insurer
- The patient can use HSA funds to pay qualified medical expenses, including deductibles and copays, tax-free (Correct answer)
- HSA funds can only be used after the deductible is fully met
- The patient cannot use an HSA for inpatient services
Correct answer: The patient can use HSA funds to pay qualified medical expenses, including deductibles and copays, tax-free
HSA funds are available tax-free for qualified medical expenses, including deductibles and copays, and communicating this helps patients plan for cost-sharing.
CRCR CRCR - Certified Revenue Cycle Representative Program Insurance Verification and Authorization 4
A patient scheduled for an inpatient admission has Medicare as primary and Medicaid as secondary.
The hospital verifies Medicare eligibility but skips Medicaid verification.
What risk does this create?