Certified Revenue Cycle Representative (CRCR) Practice Exam

How does utilization review staff use correct insurance information?

1. To calculate hospital profit margins

2. To obtain approval for inpatient days and coordinate services

3. To determine patient eligibility for various services

4. To identify potential fraud cases

The correct answer is: To obtain approval for inpatient days and coordinate services

Utilization review staff play a critical role in ensuring that patients receive appropriate care while also managing healthcare costs. By using correct insurance information, they are able to obtain approvals for inpatient days and coordinate the necessary services for patients. When the utilization review team has accurate insurance details, they can determine what benefits and coverage the patient is entitled to. This knowledge enables them to secure authorizations for specific medical services, including inpatient admissions and extended stays. Without correct insurance information, there could be delays in service delivery or denials of coverage, which can adversely affect patient care. Additionally, accurate insurance information is key to coordinating services among different providers to make sure that the patient's care is seamless and effective. Thus, the ability to obtain approval for inpatient days and coordinate services directly depends on having the right insurance details, making it the most relevant choice concerning the utilization review process.