PAR Financial Clearance and Counseling 3 — Questions and Answers
Question 1: 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?
- Premium ceiling
- Out-of-pocket maximum (Correct answer)
- Benefit limit
- Deductible cap
Correct 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.
Question 2: A patient's insurance card shows 'HMO.' What referral requirement should the PAR communicate to the patient?
- No referrals are ever needed under HMO plans
- A referral from the primary care physician is typically required to see a specialist (Correct answer)
- Referrals are only needed for out-of-network specialists
- HMO plans always waive referrals for urgent care
Correct 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.
Question 3: Which document must a patient sign to acknowledge they understand their financial responsibility if Medicare is expected to deny a claim?
- Assignment of Benefits form
- Notice of Privacy Practices
- Advance Beneficiary Notice of Noncoverage (ABN) (Correct answer)
- HIPAA Authorization
Correct 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.
Question 4: Which income-based program provides health coverage for low-income families, children, pregnant women, and certain adults?
- Medicare Part B
- TRICARE Reserve Select
- Medicaid (Correct answer)
- COBRA
Correct answer: Medicaid
Medicaid is a joint federal-state program that provides health coverage to eligible low-income individuals and families.
Question 5: A patient calls to ask about setting up a payment plan for a $1,200 balance. What information should the PAR collect first?
- The patient's credit score
- The patient's ability to pay, income information, and preferred payment schedule (Correct answer)
- The patient's next of kin contact details
- Whether the patient has consulted an attorney
Correct 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.
Question 6: An 'Assignment of Benefits' form authorizes which action?
- The patient to receive a second medical opinion
- The insurer to pay the healthcare provider directly instead of the patient (Correct answer)
- The hospital to release medical records to the employer
- The patient to waive their right to an itemized bill
Correct 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.
Question 7: What is the role of a financial counselor in a hospital's Patient Access department?
- To approve medical procedures on behalf of the physician
- To help patients understand their financial obligations and explore payment or assistance options (Correct answer)
- To negotiate rates with insurance companies on behalf of the hospital
- To audit clinical documentation for billing compliance
Correct 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.
PAR Financial Clearance and Counseling 3
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?