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Use these four tips to improve your radiology payment odds

HIM Connection, June 6, 2006

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Use these four tips to improve your radiology payment odds

Although hospital radiologists can order additional tests without consulting the primary care physician (PCP) and still be in compliance, these orders aren't always reimbursed. Christine Donovan-Hall, an independent imaging consultant in Brunswick, ME, and William Malm, ND, RN, president of Health Revenue Integrity Services, Inc., in Cleveland, offer the following tips for HIM professionals to get these tests reimbursed:

1. Call the insurance company and ask for an authorization number. Getting an authorization number assures your reimbursement. The problem is that this often takes 24 hours, depending on the company.

   "For many of the managed Medicaid products this can sometimes even exceed a week to complete," Malm says.

2. Instruct radiologists not to perform a second exam. Create a policy that the patient must return at a different date for a second exam, and have the ordering physician obtain a preauthorization in the meantime.

   For example, if the patient has a reported diagnosis that supports an abdomen-pelvis computed tomography (CT) scan but not an abdomen CT, instruct department staff to call the patient and delay the exam for a day until you can obtain preauthorization.

3. Create a verification/preauthorization department. When the physician calls in, a verification/preauthorization department preliminarily schedules an exam for the patient, depending on verification of insurance and whether the physician has a preauthorization.

   Staff in this department ensure that the patient is preauthorized with the insurance company and then contact the appropriate physician's office or physician to set up a date and time for the exam.

   Note that many insurance products/plans require a separate authorization number for facility and physician components. Consult your managed care coordinator and develop a matrix of what is required of each payer and plan.

   "This will allow the registration/scheduling staff to ensure completeness of authorization," says Malm. Many hospitals have centralized scheduling, which involves a scheduler sending the information to a preauthorization representative. If your hospital employs this practice, Donovan-Hall recommends color-coding documents depending on whether the patient's test requires verification.

   For example, yellow claims indicate to staff that the patient's test needs to be preauthorized or requires other attention, whereas green indicates that the test is preauthorized by the insurance company.

   "This makes it better for the patient because nobody wants to come in and have a test and then have to return at another date for a second test," Donovan-Hall says.

4. Schedule educational sessions between radiologists and physicians. Radiologists need to update physicians to keep them abreast of new diagnostic technology. This can help physicians order the right test the first time and eliminate the need for follow-up tests, which may result in denials. For example, a physician may order an ultrasound instead of a more appropriate CT exam.

   "Physicians often don't grasp angiography exams, like CT or MR [magnetic resonance]," Donovan-Hall says. "Many hospitals now have 16- and 64-slice CT scanners and can perform these exams, where with a single-slice CT scan they could not."

   Involve the physician billing staff in these educational sessions, suggests Malm. "They can sometimes assist the physician in determining how this affects their private practice, and it leads to enhanced compliance and an improved revenue stream."

Editor's Note: This article was adapted from the newsletter Briefings on APCs, published by HCPro, Inc.

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