Radiology Administrator's Compliance & Reimbursement Insider, November 2006

Many doctors in small offices have just not adjusted to the reality of managed healthcare, she adds. “But the process is what the process is. It’s more costly if it’s not done right.” To combat such lethargy, create a package of useful precertification information and get it out to referring physicians. Schedule follow-up meetings to reiterate the importance of adhering to proper precertification protocols and go over any potential problem areas.

“They are unfamiliar with the [CPT]codes. When we suggest a code change, they react. ‘This is the scan that’s needed,’ they tell us,” she says.

For example, the physician may say Mrs. Jones needs a CT scan of the neck, but what he or she really means is a CT scan of the cervical spine based on the clinical indications. When the receptionist gets on the phone with the medical staff at CareCore, the receptionist may or may not understand what clinical indications go with what scan.

“If we get the doctor on the phone, we can just change the precertification scan request right then, but otherwise it can be an uphill battle,” she says, which ultimately results in claim denials, lost revenue, and plenty of ill will.

Have the patient report beside the phone when making a precertification request, she suggests. Many of the particulars are included in the report. Also, have the referring physician spend an extra minute explaining the situation to the person requesting the precertification. A two-minute conversation can save 30 minutes on the telephone or days of precertification paperwork related to a potential denial.

Overall, the biggest need is training, she adds.

“Doctors need to know how to navigate precertification, so any training they get can be extremely valuable,” she says. “So, give it to them.”

Insider source

Shelley N. Weiner, MD, FACR, senior medical director, CareCore National, LLC, 169 Myers Corners Rd. Wappingers Falls, NY 12590, 845/298-8155; SWeiner@CareCoreNational.com.

Simple steps to effective audits

To the uninitiated radiology administrator, it’s a nightmare—the audit team is on its way. It wants a wide range of documentation in a seemingly wild search for underlying billing evils. More compliance officers are asking radiology administrators to wake up to the benefits of regular audits and to conduct self-audits to head off problems.

What’s an audit, anyway?

Audits are an opportunity to examine the accuracy of your records and accounts. Essentially, auditors gather and evaluate evidence to establish connections between particular beliefs and the actual information. The auditor then creates a report to communicate the results to anyone interested (e.g., managers, board members, etc.).

There are three types of auditors: internal, external (i.e., those that are contracted by your facility), and governmental.

“You don’t want governmental [audits/auditors]. They don’t have a clear goal. They come in and look at everything,” said Andrei M. Costantino, MHA, CHC, CPC-H, CPC, director of organizational integrity at Trinity Health in Novi, MI. He spoke during the American Health Radiology Administrators’ annual meeting in Las Vegas earlier this year.

Why audit?

Auditors generally look for a variety of problems, from billing and coding mistakes to incorrect charts. Congress and the Department of Justice continue to watch hospital management. The more prepared your facility is prior to an unannounced governmental audit, the better, Costantino said.

“The government constantly looks at what we’ve done,” he said. “You’ve got to keep moving forward, but you can’t stop worrying about the past either.”

How to conduct an audit

1. Plan and organize. Define your objective and purpose. This can be tricky, because you don’t want your scope to be too broad or too narrow, said Costantino.

“You may think that there might be a problem in a certain area—start there,” he said.

Pick an initial concern, such as one of the following examples offered by Costantino:

A clearly defined objective influences not only the audit process, but also the outcome. The purpose that you define inherently skews the investigation and the resulting action points or decisions.

2. Outline the sample collection. Now you will need to determine what kind of data are best suited to answer your initial question or concern, said Costintino.

For example, perhaps you believe that a problem exists with the billing information on the UB-92 form. Take a look at the form and the information required to fill it out. Such data include the following:

“There are so many opportunities for a claims denial here,” he said. “The chances to audit appropriately and improve fiscal outcomes can be great.”

Sample these forms over time and analyze the resulting data. Experts often recommend asking someone in the office to review 10 claims per week and look for a certain problem.

“Now you have a concise window of information to work with,” said Costantino.

Keep your audit topics and data collection sets consistent year after year to help to eliminate bias and develop data continuity, he says. Of course, consistency makes your job easier, too. The next time around, you’ll just have to input data, not reinvent the wheel.

3. Create a schedule. Identify the other departments or people with which you want to partner. Then talk to them.

Tell them what information you need, and why you need it. Help them to understand how the audit will improve the overall effectiveness of the facility and the bottom line. Create regular, reasonable deadlines so they’ll be able to comply.

Don’t ask them to get the data to you ASAP—that’s a recipe for disaster. But you don’t want to set a completion date so far away that your coworkers forget all about the audit. Established timelines create achievable goals, Costantino said.

Don’t be afraid of audits, he added. The paperwork nightmare may just end up fulfilling your facility’s fiscal dreams by uncovering subconscious mistakes.

“More often than not, audits do not uncover fraud,” said Costantino. “They discover billing errors. Of course there are bad players out there, but mostly people do their jobs to the best of their abilities. Mistakes are due to misunderstandings, lack of knowledge, technological breakdowns, and bad advice.”

Through audits, you can find these problems—and you can fix them.

Insider source

Andrei M. Costantino, MHA, CHC, CPC-H, CPC, director of organizational integrity, Trinity Health, 34605 W. Twelve Mile Rd., Novi, MI, 248/324-8479; costanta@trinity-health.org.

Auditing for radiology administrators: A sample audit checklist

Use or overuse? The reality behind the regulations

At the heart of every myth lies the essence of truth. The exponential growth of imaging and its effect on healthcare’s bottom line profoundly affects not only the future of healthcare, but the future of health itself.

For example, a mother can now see her unborn baby in perfect, three-dimensional (3-D) view. A grandfather with no previous history or other indications of heart trouble can see his beating heart and learn of potential risks early enough to counteract them.

Advancing technology makes these scenarios possible. But it’s just one reason for imaging’s rise from a supportive role to a lead character on healthcare’s mythological stage. Patient/consumer demand represents another reason for such growth, Shay Pratt, a senior consultant at The Advisory Board Company in Washington, DC, told an audience during the Radiology Business Management Association’s annual meeting in Miami in June.

Changing protocols in the world of radiology allow for more formalized procedures, which, in turn, create easier processes and better throughput. A greater number of scans become possible because the industry knows how to handle the increased caseload.

Utilization creep has also occurred in recent years, because scans once dubbed “investigational” now have CMS and local coverage determination approval, said Pratt. In essence, more payers accept more diagnosis codes for more scans.

The growth of imaging services has turned it into the “pillar of profitability,” Pratt said. In 2005, hospital outpatient systems across all payers earned $20.9 billion, according to an Advisory Board report.

However, no myth can be free of demons. Cutting-edge technology costs money, and such expansion has instigated increased scrutiny from government and private insurers alike.

A 3-D Doppler ultrasound may be beautiful, but it may not be necessary. The radiologist may find an abnormal tick in that grandfather’s heart, but the cost of such a scan makes its widespread use prohibitive.

Because some see radiology as the proverbial golden fleece, the temptation to offset other practices on the back of imaging’s fine fibers can be great. To balance the benefits of increased imaging use with healthcare’s ever-tightening coffers, payers and governmental agencies have created challenges for referring physicians and radiologists to overcome.

For example, an overview of CMS’ Medicare Physician Fee Schedule (MPFS) proposed rule for 2007 includes the implementation of the following two provisions of the Deficit Reduction Act of 2005 affecting payment for imaging services under the fee schedule:

1. -The first provision addresses payment for certain multiple imaging procedures, with full payment for the first procedure, but a 25% reduction in payment for additional imaging procedures furnished on contiguous body parts during the same session. This is a smaller reduction than had previously been proposed.

2. -The second provision limits the payment amount under the MPFS to the outpatient department payment amount for the technical component of certain imaging services. Under this provision, the physician fee schedule payment amount for furnishing certain imaging procedures would not exceed the amount that is paid to an outpatient department.

Further, imaging practice ownership regulations continue to evolve as the industry evolves. As of January 1, 2007, nuclear imaging will fall within the realm of designated health services and under the purview of the Stark Law. Many hospitals will be forced to untangle their joint venture agreements to keep from getting bitten by government regulations.

Payers have created their own cost-cutting procedures, as well, said Pratt, which is where precertification—and imaging intermediaries—come in. These procedures include the following:

Imaging management companies offer large payers big financial returns by implementing any number of these procedural fail-safes.

For example, National Imaging Associates, Inc., measures physician ordering patterns. CareCore National, LLC, offers clinical certification, referral profiling, privileging, correct coding, and network management programs tailored to payers’ imaging needs. CareCore National measures physician ordering patterns and helps payers to establish quality standards for in-network imaging providers. American Imaging Management and HealthHelp also measure physician ordering patterns and assist in developing quality standards. “These companies clearly meet a demand,” said Pratt.

Precertification, or use management, may just be one obstacle in the path of our mythological storyline. However, it has clearly become the maze to navigate for imaging reimbursement, she said.

Insider source

Shay Pratt, senior consultant, The Advisory Board Company, 2445 M St., Washington, DC; pratts@advisory.com.

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