Where some specialties enjoy prior authorization rates under 10%, payers request prior authorizations for 91% of all radiology services.
Radiologists know that nearly all of the treatments they propose will need prior authorization. While 88% of all physicians characterize the prior authorization burden as “high” or “extremely high,” radiologists’ shoulder one of the heaviest prior authorization burdens of all specialties.
The radiology clinic affiliated with a 125-center East Coast health system was aiming to market its services to more practices in the area. Named the top healthcare provider in the state by several organizations, this system offered primary care, oncology, sleep medicine, fertility, rheumatology, and many more services.
In addition to handling the imaging work for these specialties, the radiology center wanted to entice outside practices with the promise of handling all prior authorizations for them, a common aggravation. Given a nationwide healthcare staffing shortage and other issues, they knew backing up this promise would require prior authorization support.
Growing Prior Authorization Workload Requires System Transparency
Before making its best case to outside referring providers, this imaging center needed to streamline and optimize its own internal prior authorizations. These came in regularly from the system’s clinics and centers. Patient volume was outstripping staff capacity and prior authorizations were falling behind.
They had another challenge, however. The doctors in their cardiology wing were pushing hard to get more patients an “experimental” imaging procedure. Code CPT 75571 is for a non-contrast CT of the heart with calcium scoring. Radiology leaders needed to determine why payers were denying this procedure the most to determine whether it was cost-effective to even offer it. Performed only when calcium scoring is performed as a stand-alone procedure, many payers resist paying for it. In fact, the payer denial rate for this procedure was 71%. The imaging wing’s denial rate for all other procedures averages 14%. Of the 35 cases for which they requested prior authorizations, 25 were denied by five large payers, mostly Blue Cross / Blue Shield.
Preparing To Handle Increased Volume
Finally, to serve the outside providers it was targeting, the imaging center wanted to be able to handle a larger prior authorization caseload. It knew that the practice staff member in charge of prior authorizations would most likely be a front desk employee also handling eligibility, check-in and check-out, scheduling, and more. The prospect of having prior authorizations handled outside the practice staff member’s workload would appeal to practices, which are typically overburdened.
The radiology center evaluated several prior authorization solutions. They appreciated our experience working with the local New Horizon Blue Cross / Blue Shield system, as well as the support we could provide as they scaled. Leaders were relieved to see that we had prior authorization team members who were specialists in radiology. Deep context and knowledge in the area goes far in reducing errors and denials.
Infinx Chosen To Provide Prior Authorization Support And Denials Analysis
We established with the client that our common goals were to:
- streamline current prior authorizations
- accommodate growing prior authorization processing volume
- explore the opportunities and challenges surrounding the “experimental” imaging procedure, non-contrast CT of the heart with calcium scoring (CPT 75571)
Most of the work we would do pertained to CT and MRI scans.
The client entered case details and patient data manually into our portal. We conducted the prior authorization process, ensuring all steps were completed and payer-required documents included.
The solution automatically submitted the prior authorization to the payer in most cases. In complex cases, however, our interventional radiology prior authorization specialists intervened to get what’s needed from the practice so that the payer is most likely to approve.
The power of a two-pronged automation-plus-specialists approach ensures all prior authorizations are addressed. Solutions that depend only on automation send some prior authorizations back to practice staff to conduct follow-up. Staff have learned well that this time-intensive process keeps them from patient care. During a staffing shortage, reworking denied prior authorizations can be overlooked entirely.
Hands-On Support For Stalled Prior Authorizations
When the client reached out to us about a stalled prior authorization or another issue, a specialist called the payer for insights. The specialist then relayed exactly what was holding up the prior authorization and made recommendations for what to provide the payer to resolve the issues. Our deep expertise in dealing with specific radiology issues provided significant value and time savings for the client.
Exploring “Experimental” Procedure Practicality & Profitability
We also began our exploration of the data surrounding the “experimental” imaging procedure, non-contrast CT of the heart with calcium scoring (CPT 75571).
Clear Guidance At Onboarding
During onboarding, the client’s customer success manager demonstrated how to use the portal, demonstrating the notifications that ensure all details are included.
Weekly meetings are standard, but our CSM is available at any time to resolve issues quickly. Given the urgency of radiology prior authorizations, our team responds to any emails the client sends within 10 minutes. Issues can take three days or fewer to resolve.
Prior Authorizations Turned Around In 2 Days
Our team’s deep radiology expertise fueled fast and accurate prior authorization turnarounds. The center would enter patient and case data in the evening, and we would start the prior authorization process the next morning. The center would then receive the prior authorization approval or denial within an average of two days.
With our prior authorization capabilities established, the director was ready to entice new ordering physicians in the community with prior authorizations done for them at no cost. If they got the radiology center the data, it (our team) would process the prior authorizations. With this task removed from the providers’ workload, often overburdened front-end provider teams could focus more on patient care. This enticement proved valuable in the center’s efforts to expand their pool of outside ordering physicians.
Clear Answers On The Feasibility Of The Experimental Scan
Our team was also adept at researching payers’ guidelines for experimental scan, CPT 75571. We made clear to the radiology director the exact requirements and documentation it would take to get that procedure approved for several payers. Given all payers’ extensive demands, after some consideration, the director decided it was more cost-effective to offer alternatives to the procedure.
Finding The Procedures That Pay
Our denial analysis—which includes their top codes and payer variations—provided the clarity to help the center’s director make important decisions. We shared which procedures they were most likely to get paid for and which wouldn’t. We encouraged them to work closely with the payers to build relationships that would ease approval for future cases. During our quarterly business reviews, we share our documented turnaround times to demonstrate how we were sticking to our promised efficiencies.
A Satisfied, Scaling Radiology Center
Where this client started with a trial run of just five cases per week, today we handle 100 prior authorizations for them weekly. These include the authorizations coming from within their system and those from the outside providers that use their services.
The client is relieved that they didn’t need to search for more staff to get their prior authorizations processed quickly and accurately. They are impressed with the radiology knowledge our specialists demonstrate and appreciate the insights they gain from their quarterly business review. That clarity helps them make optimal staffing, procedure, and other business decisions. They share that they are looking forward to consistent growth and feel confident they can accommodate all new outside provider partners.
If you are looking to achieve similar results at your organization, contact us at www.infinx.com/request-a-demo.
Looking to grow your revenue without hiring more staff? Explore how one growing East Coast radiology network offered local providers free prior authorization services as an enticement to partner.