Certified Revenue Cycle Representative (CRCR) Practice Exam

When an undue delay of payment results from a dispute between the patient and the third-party payer, who is responsible for payment?

1. Payer

2. Provider

3. Patient

4. Insurance mediator

The correct answer is: Patient

In situations where there is an undue delay in payment due to a dispute between the patient and a third-party payer, the responsibility for payment typically falls on the patient. This is grounded in the principle that patients have an obligation to ensure that their insurance claims are processed and paid appropriately. If a dispute arises over coverage or payment issues, it is essential for the patient to take an active role in resolving those disputes with their insurer. While the payer has an obligation to process claims and communicate decisions, a delay caused by a disagreement means that the patient may still be liable for the costs incurred unless the dispute is resolved favorably for them. The healthcare provider may be involved in efforts to negotiate or clarify the situation, but ultimately, in the absence of payment from the insurer, it is the patient who may be required to cover the costs until the matter is addressed. This understanding emphasizes the patient's role in their own revenue cycle and reminds them of the importance of maintaining communication with both their healthcare providers and insurance companies.