Financial Clearance and Counseling Flashcards

Under the Affordable Care Act, what is the term for the annual cap on how much a patient must pay out-of-pocket for covered services?

Answer: Out-of-pocket maximum

The out-of-pocket maximum is the ACA-mandated limit on total annual cost-sharing (deductibles, copays, coinsurance) a patient owes.

A patient's insurance card shows 'HMO.' What referral requirement should the PAR communicate to the patient?

Answer: A referral from the primary care physician is typically required to see a specialist

HMO plans generally require a referral from the patient's primary care physician before specialist visits are covered.

Which document must a patient sign to acknowledge they understand their financial responsibility if Medicare is expected to deny a claim?

Answer: Advance Beneficiary Notice of Noncoverage (ABN)

The ABN notifies Medicare beneficiaries that a specific service may not be covered and that they will be responsible for payment.

Which income-based program provides health coverage for low-income families, children, pregnant women, and certain adults?

Answer: Medicaid

Medicaid is a joint federal-state program that provides health coverage to eligible low-income individuals and families.

A patient calls to ask about setting up a payment plan for a $1,200 balance. What information should the PAR collect first?

Answer: The patient's ability to pay, income information, and preferred payment schedule

Establishing a viable payment plan requires understanding the patient's financial situation and how much they can reasonably pay per period.

An 'Assignment of Benefits' form authorizes which action?

Answer: The insurer to pay the healthcare provider directly instead of the patient

By signing an Assignment of Benefits, the patient directs their insurer to pay the provider directly for covered services.

What is the role of a financial counselor in a hospital's Patient Access department?

Answer: To help patients understand their financial obligations and explore payment or assistance options

Financial counselors educate patients about their cost-sharing responsibilities and connect them with assistance programs, payment plans, or Medicaid enrollment.