PAR Denial Management and Point of Service Collections Flashcards

What is 'balance billing' and when is it prohibited?

Answer: Charging a patient the difference between a provider's billed charge and the insurer's allowed amount; prohibited for in-network providers under most contracts

Balance billing charges patients more than the contracted rate, and in-network providers are contractually prohibited from billing patients beyond their required cost-sharing (deductible, copay, coinsurance).

Under the 'birthday rule' for COB, how is the primary insurer determined for a dependent child?

Answer: The parent whose birthday falls earlier in the calendar year has the primary plan for the dependent child

The birthday rule states that when a child is covered under both parents' plans, the plan of the parent whose birthday (month and day) falls first in the calendar year is primary.

What is 'subrogation' in the context of health insurance?

Answer: The right of an insurer to seek reimbursement from a liable third party after paying a claim on behalf of the insured

Subrogation allows an insurer that paid a medical claim to recover those costs from a third party (such as a liability insurer) that is ultimately responsible for the injury.

What is 'medical necessity' and why does it matter for claims?

Answer: Services or supplies that are appropriate and consistent with the diagnosis, meeting accepted standards of care; required for insurers to pay claims

Medical necessity means that a service is appropriate, reasonable, and consistent with evidence-based clinical standards, and payers require it to be established before paying claims.

What is an 'appeal' in the medical billing process?

Answer: A formal request to an insurer to reconsider a denied or underpaid claim with supporting clinical or administrative documentation

An appeal is a written request submitted to a payer asking them to overturn a denial or increase reimbursement, typically accompanied by supporting clinical documentation or coding rationale.

What is the 'No Surprises Act' and how does it affect patient access workflows?

Answer: A federal law effective 2022 that protects patients from unexpected out-of-network bills and requires Good Faith Estimates for uninsured patients

The No Surprises Act limits surprise billing for emergency services and requires providers to give uninsured patients a Good Faith Estimate of expected charges before scheduled services.