Certified Revenue Cycle Representative (CRCR) Practice Exam

When a patient receives non-emergent services from an out-of-network provider, what is the likely effect on the patient?

1. Lower out-of-pocket costs

2. Higher payment responsibility

3. Access to additional services

4. Eligibility for special insurance benefits

The correct answer is: Higher payment responsibility

When a patient receives non-emergent services from an out-of-network provider, the likely effect is a higher payment responsibility. This is primarily because insurance plans typically have different benefits for in-network and out-of-network providers. In-network providers have pre-negotiated rates with the insurance company, which generally results in lower out-of-pocket costs for the patient. Conversely, when a patient chooses an out-of-network provider, they may not receive the same level of coverage. The patient could face higher deductibles, copayments, or coinsurance for services rendered by out-of-network providers. Some insurance plans may cover only a smaller percentage of the total bill incurred, leading to significant additional costs for the patient. Therefore, choosing an out-of-network provider for non-emergent services often results in a greater financial burden on the patient. In contrast, options suggesting lower out-of-pocket costs, access to additional services, or eligibility for special insurance benefits do not align with the reality of navigating out-of-network care, further emphasizing that the financial implications are usually more pronounced for patients in such scenarios.