Insurance Verification & Authorization Flashcards

A patient covered by a High Deductible Health Plan (HDHP) has not met their deductible. For a scheduled outpatient lab draw, what is the most accurate financial counseling statement?

Answer: The patient will be billed at the negotiated rate until the deductible is met

Under an HDHP, patients pay the insurer's negotiated (contracted) rate, not full billed charges, for in-network services until their deductible is satisfied.

When completing a Medicare Secondary Payer (MSP) questionnaire, which question is most critical for determining if Medicare should pay secondary?

Answer: Does the patient have current employment or a spouse with current employment that provides group health insurance?

Active employment status for the patient or spouse is a key MSP trigger, as active employer group health coverage with 20+ employees makes Medicare secondary.

A commercial payer's portal shows a procedure requires authorization, but the facility's internal reference database says it does not. What is the safest course of action?

Answer: Follow the payer's current portal requirement and obtain authorization

The payer's own portal reflects the most current and binding requirements; proceeding without the indicated authorization risks claim denial.

Which modifier is commonly appended to a CPT code to indicate that a service was performed by two surgeons, each performing distinct parts of a procedure, for the purpose of prior authorization review?

Answer: Modifier 62

Modifier 62 is used when two surgeons work together as co-surgeons performing distinct parts of a reportable procedure, and payers may require this on authorization requests.

A patient's plan shows 'in-network deductible: $1,500; out-of-network deductible: $4,000.' The patient is scheduled at an in-network facility but the anesthesiologist is out-of-network. Under the No Surprises Act, which deductible applies to the anesthesiologist's charges?

Answer: The in-network deductible of $1,500, as if the anesthesiologist were in-network

The No Surprises Act requires out-of-network providers in certain contexts (like facility-based anesthesia) to be treated as in-network for cost-sharing purposes.

What does 'retro-authorization' refer to in insurance verification workflows?

Answer: Seeking payer approval for a service that has already been rendered

Retro-authorization is the process of obtaining payer approval after a service has already been provided, often required for emergency admissions or when standard pre-authorization was not obtained.

Which of the following is a common reason a payer would issue a 'concurrent review' request during an inpatient stay?

Answer: To assess ongoing medical necessity and determine whether continued inpatient stay is justified

Concurrent review allows payers to evaluate whether continued inpatient care remains medically necessary as the patient's clinical status evolves during the stay.