Financial Clearance and Counseling Flashcards

A patient is uninsured and qualifies for Medicaid based on income screening at registration. What is the PAR's best next step?

Answer: Assist the patient in completing a Medicaid application before discharge or scheduling

Assisting uninsured patients with Medicaid applications at point of service improves coverage rates and reduces bad debt for the facility.

Which of the following best explains the difference between an 'in-network' and an 'out-of-network' provider?

Answer: In-network providers have contracted rates with the insurer; out-of-network providers have not, often resulting in higher patient costs

In-network providers have negotiated discounted rates with the insurer, while out-of-network providers have no such contract, typically leading to greater cost-sharing for patients.

A patient refuses to provide insurance information and insists on being treated as self-pay despite appearing to have coverage. What should the PAR do?

Answer: Honor the patient's decision, document it, and proceed with self-pay financial counseling

Patients have the right to decline use of their insurance; the PAR should document the refusal and counsel the patient on their self-pay financial obligations.

What is a 'remittance advice' (RA) and why is it important to Patient Access financial operations?

Answer: An insurer's explanation of how a claim was processed, including payment amounts and any denials or adjustments

The remittance advice details the payer's adjudication of each claim, showing payments, denials, and contractual adjustments, which informs follow-up and appeals.

Which of the following scenarios requires an Emergency Medical Treatment and Labor Act (EMTALA) screening regardless of the patient's ability to pay?

Answer: A patient arriving at the emergency department with chest pain

EMTALA requires hospitals to provide a medical screening examination to anyone presenting to the ED with an emergency medical condition, regardless of ability to pay.

A patient's Explanation of Benefits (EOB) shows a 'contractual adjustment.' What does this represent?

Answer: The amount the provider must write off due to the contracted rate agreement with the insurer

A contractual adjustment is the difference between the provider's billed charge and the negotiated rate, which the provider agrees to write off as part of the network contract.

When screening a patient for financial assistance, which piece of information is most critical for determining eligibility for most charity care programs?

Answer: The patient's household income relative to the Federal Poverty Level (FPL)

Most charity care and financial assistance programs use income relative to the Federal Poverty Level as the primary eligibility criterion.