Compliance tips for second tests

Sometimes, the ordering physician doesn’t order the most appropriate diagnostic test the first time due to a lack of understanding of recent advances in technology, Donovan-Hall says.

“They order what they think is right. But often, there are new technologies that can see more than the old tests,” she says. “It’s just a matter of your radiologists educating your referring physicians.”

Payment problems

Many insurance companies require preauthorization for expensive diagnostic tests, such as CTs and magnetic resonance imaging (MRI).

Radiologists often take the next step of calling the treating physician and obtaining a verbal order for the test (and later documenting it in the medical record), or they write the order themselves for billing purposes.

However, payers often balk at reimbursement of the claim, Donovan-Hall says.

Although it’s compliant for a hospital radiologist to perform an additional or secondary exam, “the problem lies with getting authorizations for those exams, especially the high-dollar exams,” she says. “Insurance companies are really cracking down on preauthorizations.” Good verifications and good scheduling are the most important things for hospitals.”

Additionally, Medicare requires a specific medical necessity diagnosis for many CT and MRI exams and interventional procedures, Malm notes. If the hospital does not meet this diagnosis requirement, Medicare requires that the facility complete an advance beneficiary notice process prior to beginning the test/procedure.

“This continues to be an operational issue throughout most facilities when they add or change tests, [because] frequently the patient is already in the examination room,” says Malm.

Editor’s note: This article first appeared in the HCPro, Inc., publication Briefings on APCs and can be found online at www.hcpro.com/pub-116.html.

Use these four tips to improve second test payment odds

Although hospital radiologists can order additional tests and still be in compliance, insurance companies and Medicare don’t always pay for these orders.

“The caveat is, will the hospital get paid for the order? That’s the problem,” says Christine Donovan-Hall, an independent imaging consultant in Brunswick, ME. She and William Malm, ND, RN, president of Health Revenue Integrity Services, Inc., in Cleveland, offer the following tips for health information management professionals to get paid for these tests:

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

“For many of the managed Medicaid products, this can 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.

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

3. Create a verification/preauthorization specialist. Assign staff to ensure that the patient is preauthorized for the exam with the insurance company prior to establishing a date and time for the exam.

Note that many insurance products/plans require a separate authorization number for both the facility and physician components.

Consult your managed care manager 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 preauthorization or requires other attention, whereas green indicates that the insurance company preauthorized the test.

“This makes it better for the patient because nobody wants to come in for 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 informed about new diagnostic technology.

This helps physicians order the right test the first time and eliminates 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 [magnetic resonance imaging],” 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,” he says. “Such discussions often lead to enhanced compliance and an improved revenue stream.”

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