The pitfalls along the road to radiology billing reimbursement are many. Denials and delays are not only highly frustrating to your imaging center, but they also represent a potential delay in care for the patient, wasted physician hours, and idle machines.

Over the past two years, imaging centers have seen a surge in prior authorization denials – in some cases as much as 300 percent. In addition to an increasing number of procedures requiring an authorization, imaging centers across the country face issues with meeting clinical requirements due to lack of documentation from referring physicians and constant changes to payer and benefit managed policies and guidelines.

Research shows a link between each week of delay in starting cancer therapy and increased risk of death. In a 2018 survey by the American Society for Radiation Oncology, 93 percent of respondents said their patients are delayed from lifesaving treatments due to prior authorization requirements, and 31 percent said the average length of treatment delay is longer than five days.

With these troubling statistics in mind, here are five common radiology billing mistakes that can affect timely reimbursement.

1. Not obtaining prior authorization before the appointment

In general, health carriers require prior authorization for advanced outpatient imaging procedures such as CT scans, MRIs, MRAs, PET scans, nuclear medicine studies, and nuclear cardiology services. The healthcare provider who is referring the patient for an imaging scan is responsible for requesting prior authorization before scheduling the procedure. However, the imaging care provider may contact the referring care provider and request that they obtain a prior authorization number before scheduling the imaging procedure.

If the prior authorization is not requested or verified before rendering the procedure, a claim denial could be the result— with members not being billed for the services. In order to obtain payment, the prior authorization must be supported by medical necessity, filed on time, and filed by the provider mentioned in the referral or authorization. If one or all of these requirements are not met, reimbursement can be delayed or even denied.

2. Missing information in the claim

Accuracy counts when it comes to prior authorization. Any missing information may be cause for denial. Forgetting any one of the following could account for denial or delay of service:

  • Patient name
  • Patient address
  • Patient phone number
  • Patient date of birth
  • Patient identification and group number
  • Ordering care provider’s name
  • Ordering care provider’s tax number
  • National Provider Identifier number
  • Ordering care provider’s mailing address
  • Ordering care provider’s phone and fax number
  • Ordering care provider’s email address

Depending on the health carrier or plan, requirements can also include the imaging procedure being requested with the distinguishing code, the working diagnosis with the appropriate code, the patient’s clinical condition including any symptoms, listed in detail, with severity and duration, treatments that have been received, including dosage and duration for drugs; and dates for other therapies, dates of prior imaging studies performed, and any other information that the
care provider believes will help in evaluating whether the service ordered meets current evidence-based clinical guidelines, including but not limited to, prior diagnostic tests and consultation reports. Finally, to help ensure proper payment, the ordering care provider must communicate the authorization number to the rendering care provider.

If a claim is denied for not completing the prior authorization process because the wrong insurance information was presented to the care provider, the rendering care provider can usually submit an appeal.

3. Incorrect patient identifier information

Perhaps the only thing worse than completely forgetting to enter information is entering the wrong information. To guarantee timely reimbursement, ensure the patient’s name is spelled correctly, the date of birth and sex are accurate, the correct insurance payer is entered and the policy number is valid.

In addition, be sure to check whether or not the claim requires a group number, the patient’s relationship to the insured is accurate, and the diagnosis code matches the procedure performed. Finally, make sure the primary insurance is listed as such, in the case of multiple insurances.

4. Missing documentation

Sometimes a payer requires medical records that support medical necessity before it can adjudicate a claim. This may include the patient’s medical history, physical reports, physician consultation reports, discharge summaries, radiology reports and/or operative reports. Medicare reimbursement for radiology also recognizes medical necessity as a deciding factor for claims payment and processing. Documentation is key to filling both private and public radiology
billing guidelines.

5. Services not covered or coverage is terminated

Understanding the patient’s plan and the services you are providing is important. Because insurance data can change, it’s important to verify eligibility every time services are provided. Ensure the patient’s coverage has not been terminated, their maximum benefit has not been met, and the radiology service you’re providing is covered by their plan.

If prior authorization is not granted, a letter will be typically sent to the patient and his or her health care provider explaining the reason for the decision. If either party disagrees with the decision, there is usually an appeal process or some type of avenue to file a complaint or grievance and/or request a hearing. This can result in considerable delays. However, 62 percent of respondents in the 2018 American Society for Radiation Oncology survey said most denials they receive from prior authorization review are overturned on appeal.

Infinx delivers AI-driven prior authorization and denial management solutions to help imaging centers preserve and collect more revenue. Discover innovative and scalable patient access and revenue cycle management solutions that combine cutting edge, cloud-based software driven by artificial intelligence and automation, with exception handling by certified prior authorization and billing specialists.

Schedule a demo to see how our solutions can help maximize your revenue today.