What’s one of the most perplexing problems in many imaging centers today?  Without a doubt, claim denials must be at or near the top of everyone’s list.

Complex approval processes and requirements that differ by health insurance plan make claims management a challenge for even the most well-informed billing administrator.  It’s not enough to rely on the status quo, imaging centers today must be proactive in developing plans to improve operations and patient access procedures, as well as their revenue cycle management (RCM) to meet the test.

Medical Claim Denials Meet Bottom Line

At a recent RBMA symposium, a study (accepted industry-wide) by the Medical Group Management Association (MGMA), estimates the cost to rework a claim that has been denied by insurance is $25.00 for each occurrence.  And even more impactful is the fact that between 50% and 65% of denied claims go unchallenged due to lack of time and/or understanding on how to proceed and the revenue is lost completely.

Best Practices to Reduce Imaging Center Denials

The first step should be an honest review of center operations to identify where you’re meeting and/or exceeding financial expectations and where systems need to be improved.  To ensure impartiality and guarantee a forthright and authentic evaluation, it’s important to create an agreed-upon set of criteria that’s outpatient and ambulatory specific before performing the actual audit.

In fact, as part of a “best practices” program, auditing your business operations every quarter ensures that defined procedures are being followed while allowing for advances to be implemented in a timely fashion.

10 Ways to Positively Impact Imaging Center Denials

  1. Collect accurate demographic and insurance information and provide precise entry into your EHR/EMR.  It is essential to ensure factual and meticulously verified patient information is collected and utilized for the healthcare payment lifecycle, including:
    • Subscriber or patient’s full name correctly spelled
    • Relationships between patient and subscriber verified
    • Use of full names, and not nicknames
    • Accurate primary and secondary insurance information
    • Subscriber/patient number
    • group/plan number
    • correct insurance billing address
    • Correct DOB
  2. Verify insurance prior to each visit, including:
    • Type of coverage
    • Eligibility dates
    • Coinsurance, deductibles remaining
    • Out-of-pocket maximums
    • Coverage has not been terminated
    • Services that might not be covered
  3. Obtain prior authorization (PA) approval in the most expedient manner possible and accurately document it before the patient’s visit.  To maintain a positive patient experience as well as reduce imaging center billing denials, AI-driven software using bi-directional communication allows PAs to be obtained in real-time, in most cases.
  4. Ensure proactive coding for the tests performed to eliminate missing or invalid information, including:
    • Codes that are not specific enough when each diagnosis must be coded to the highest level (maximum number of digits allowed),
    • Unbundled charges being charged separately when they are designated as part of a diagnosis bundle,
    • Use of outdated bill slips or coding books, either CPT, ICD-10, or HCPCS, which lead to inaccurate information being submitted and rejected.
  5. Confirm that referrals from a referring provider are in hand prior to the performance of the test and not cause for rejection when the claim is submitted.
  6. Guarantee that requests for documentation to support Medical Necessity are streamlined and available should they be necessary to respond to an insurance request, including:
    • Medical necessity for the right setting – does the diagnosis match the level of care, i.e., ambulatory setting vs. hospital
    • Medical necessity for the patient status – is the treatment clinically appropriate for the patient’s illness/treatment
  7. Quickly determine if your patient is presenting with a liability or work-related problem or injury so that you can properly guide them in their course of action.  The following types of insurances may take precedence and will change your handling of the situation (and the claim).  For instance, Worker’s Comp is employer-based and may have pre-defined providers and procedures.  Care should be taken to guide the patient in the right direction or risk non-payment.
    • Motor Vehicle
    • Worker’s Comp
    • Homeowner’s Insurance
    • Business Liability
  8. As a matter of routine, proper documentation should be part of the test and should be completed in a timely manner by the treating provider.  Narrative descriptions carry more weight than checklists with insurance companies.
  9. Coordination of benefits can be complicated and family situations (i.e., divorce, custody) can add an additional layer of difficulty.  At the very least, ensure that you have verified the following:
    • Establish which insurance plan is primary and which is secondary
    • Avoid duplicate claims which lead to overpayments
    • Should be reviewed annually to recognize changes
  10. Timeliness in filing can cause a claim to be rejected.  With most insurance carriers, the limit is 90 days or beyond.  While this seems like more than adequate time, all the reasons above can cause a claim to be rejected or denied for timely filing…further evidence that a proactive plan can decrease denials and increase the bottom line.

Boost Medical Claim Acceptance Rates

Developing a multi-prong approach ensures that claims acceptance rates improve.  To start, a review of rejected claims will inform the discussion and help develop steps to achieve denial prevention.

There are several high-level strategic questions that should be posed as part of this review:

  • Does the practice have an accountable RCM system with strong oversight and state-of-the-art training for new and existing personnel?
  • Would the practice benefit from improving technology with precise automated denials management that would be responsible for determining the issues and path forward?
  • What bottom-line improvements could be realized utilizing a revenue cycle partner to manage the RCM, either in part or in whole?

Contact us today to learn more about imaging center revenue enhancement strategies.