Question

multiple select question
select all that apply
which of the following is true of step 8 (monitor payer adjudication) in the revenue cycle? (more than one answer may be correct)

• when patients are covered by more than one health plan, the remainder of the claims are sent to the patients.
• the amount of payment depends on the practices contract with the payer.
• a common reason for claim denial is a failure to meet medical necessity guidelines.
• payers review the claims during the adjudication process.
• the payer will pay the provider the exact fee listed on the fee schedule.

Explanation:

Analyze Step 8 of the Revenue Cycle

In medical billing, Step 8 of the Revenue Cycle Steps is monitoring payer adjudication. Adjudication is the process where the insurance company (payer) reviews a submitted Healthcare Claim to determine payment.

Evaluate Option 1 and Option 2

• Option 1: When patients have multiple plans, remaining balances go to secondary insurance, not directly to the patient. Thus, this is incorrect.
• Option 2: The actual payment amount is determined by the contract between the provider and the payer. This is correct.

Evaluate Option 3 and Option 4

• Option 3: Payers frequently deny claims if they do not meet Medical Coding Verification or medical necessity guidelines. This is correct.
• Option 4: During Medical Claims Processing, payers review the claims to decide whether to pay, deny, or reduce them. This is correct.

Evaluate Option 5

• Option 5: Payers do not automatically pay the exact fee listed on the provider's Fee Schedules; they pay based on allowed amounts and contract terms. This is incorrect.

Answer:

• When patients are covered by more than one health plan, the remainder of the claims are sent to the patients.
• The amount of payment depends on the practice's contract with the payer. (Correct answer)
• A common reason for claim denial is a failure to meet medical necessity guidelines. (Correct answer)
• Payers review the claims during the adjudication process. (Correct answer)
• The payer will pay the provider the exact fee listed on the fee schedule.