Patient Access, Registration, and Financial Counseling
Domain 2: Patient Access, Registration, and Financial Counseling
Patient access sets the financial and clinical stage. The exam tests eligibility verification (270/271), benefits, prior authorization, coordination of benefits, MSPQ, patient estimates, point-of-service collections, and charity screening.
Core rules
- Verify eligibility before or at scheduling and re-verify on the date of service when coverage changes.
- Use payer portals and EDI 270/271; capture plan, group, subscriber, effective dates, copay, deductible, coinsurance, and out-of-pocket maximum.
- Prior authorization: confirm whether the CPT/HCPCS and diagnosis require authorization; document the authorization number and valid dates.
- Financial counseling: use allowed amounts, not charges, to estimate patient responsibility; offer payment plans and charity screening.
- Collect at point of service where policy allows; document the estimate and the patient's decision.
- Registration accuracy: name, date of birth, sex, address, and insurance identifiers; demographic mismatches cause rejections and denials.
Worked example
A patient with a $1,500 deductible remaining and 20% coinsurance schedules an outpatient procedure with an allowed amount of $2,000. Estimate: $1,500 deductible plus 20% of the remaining $500 = $100 coinsurance, so patient responsibility is $1,600 and the plan pays $400. The registrar should collect or set up a plan, not quote the $4,000 charge. Quoting charges overstates responsibility and creates complaints.
Traps
Quoting billed charges; skipping re-verification; failing to ask MSP questions; not documenting prior authorization; treating a copay as the full liability; missing network status.