10+ Senior Claims Associate Interview Questions and Answers

Authorization and COB denial handling for primary and secondary payers

• Authorization denial can occur when a service or procedure is not covered by the insurance plan

• COB denial happens when the primary payer has not paid the full amount and the secondary payer is responsible for the remaining balance

• To handle authorization denial, I would review the insurance policy and communicate with the provider to determine if an appeal is necessary

• For COB denial, I would verify the prima...read more

I loved the collaborative culture at my previous company, which fostered teamwork and innovation in handling claims effectively.

• Team Collaboration: We often held brainstorming sessions to tackle complex claims, leading to innovative solutions.

• Supportive Environment: My colleagues were always willing to help, which made it easier to learn and grow in my role.

• Recognition Programs: The company had a system to recognize outstanding contributions, which motivated us to excel in ou...read more

I have extensive knowledge about claims processing, including intake, investigation, evaluation, negotiation, and settlement.

• Understanding of insurance policies and coverage

• Experience with claims intake and documentation

• Knowledge of investigation techniques and evidence gathering

• Ability to evaluate claims based on policy terms and regulations

• Skills in negotiation and settlement agreements

I aim to enhance my analytical skills and deepen my knowledge of emerging technologies in claims processing.

• Developing advanced data analysis skills to identify trends in claims.

• Learning about AI and machine learning applications in claims processing.

• Improving negotiation skills to better resolve disputes.

• Gaining expertise in regulatory changes affecting claims management.

Bundling refers to combining multiple products or services into a single package, while inclusive means everything is included in a single price.

• Bundling involves offering a discount when multiple products or services are purchased together

• Inclusive pricing means that all features or services are included in a single price

• Bundling is common in industries such as telecommunications and software

• Inclusive pricing is often used in the hospitality industry, where guests pay a sing...read more

IPA stands for Independent Practice Association, a network of independent physicians who contract with health plans.

• Network of Physicians: IPA consists of independent doctors who collaborate to provide services while maintaining their own practices.

• Contracting with Health Plans: IPAs negotiate contracts with insurance companies to provide care to their members, often at reduced rates.

• Shared Resources: Members of an IPA can share administrative resources, such as billing and m...read more

HIPAA stands for the Health Insurance Portability and Accountability Act, ensuring patient data privacy and security.

• Established in 1996 to protect patient health information.

• Requires healthcare providers to implement safeguards for data security.

• Patients have rights to access their medical records.

• Violations can result in significant fines and penalties.

Claim process is the procedure followed by an insurance company to investigate, evaluate, and settle a claim.

• The claimant reports the incident to the insurance company

• The insurance company assigns an adjuster to investigate the claim

• The adjuster evaluates the damages and determines the coverage

• The insurance company issues a payment to the claimant if the claim is approved

• The claimant may appeal the decision if they disagree with the settlement

Claim processing is the procedure of evaluating and settling insurance claims.

• It involves verifying the claimant's eligibility for coverage

• Reviewing the claim to determine if it meets the policy's terms and conditions

• Investigating the circumstances surrounding the claim

• Determining the appropriate amount of compensation to be paid

• Communicating with the claimant and other parties involved in the claim

• Issuing payment to the claimant

• Maintaining accurate records of the claim and i...read more

RCM stands for Revenue Cycle Management.

• RCM is the process of managing the financial aspects of a patient's healthcare journey.

• It involves the administration of claims, payment collection, and revenue generation.

• RCM ensures accurate and timely reimbursement for healthcare services provided.

• It includes tasks like coding, billing, insurance verification, and denial management.

• RCM helps healthcare organizations optimize their revenue and improve financial performance.

Insurance is a financial protection against potential losses or damages.

• Insurance is a contract between an individual or organization and an insurance company.

• The individual or organization pays a premium in exchange for coverage against specific risks.

• In case of a covered loss or damage, the insurance company compensates the policyholder.

• Types of insurance include health, auto, home, life, and business insurance.

• Insurance helps individuals and organizations manage financial ...read more

Healthcare encompasses services and systems that promote, maintain, and restore health through prevention, diagnosis, and treatment.

• Includes a range of services: preventive care, treatment, rehabilitation.

• Examples: routine check-ups, surgeries, mental health services.

• Involves various professionals: doctors, nurses, therapists.

• Can be delivered in various settings: hospitals, clinics, home care.

• Focuses on both physical and mental well-being.

Auth denial is the rejection of a request for medical treatment or service by an insurance company.

• Auth denial occurs when an insurance company determines that a requested medical treatment or service is not covered under the patient's policy.

• This can happen for a variety of reasons, such as the treatment being considered experimental or not medically necessary.

• Auth denial can be appealed by the patient or their healthcare provider.

• Examples of auth denial include a request fo...read more

HMO stands for Health Maintenance Organization, a type of health insurance plan that provides a range of healthcare services.

• HMO plans require members to choose a primary care physician (PCP).

• Members need referrals from their PCP to see specialists.

• HMO plans often have lower premiums and out-of-pocket costs compared to other plans.

• Examples of HMOs include Kaiser Permanente and Aetna.