Denials on the rise for radiology claims

Payers are asking for more authorizations for high-dollar radiology procedures, and claims denials are resulting, reports Stephen Hovan, executive director of patient fiscal services at The University of Tennessee Medical Center in Knoxville, who adds that his department is seeing a 75% increase in authorizations for radiology processes. 

Claims denials occur due to the physician failing to obtain an authorization, being unaware that authorization is required, or authorizing the incorrect process, reports Hovan.

"We are in the process of implementing a rework, where the hospital will be acquiring the authorization," says Hovan. "We will also be generating the order that allows us to verify the medical necessity and the insurance, along with the precertification for the physician." This order will be faxed to the physician, who will sign it and send it back to the patient fiscal services department.

"With the advent of ICD-10 comes complexity of coding. We are investing in technology that allows for the auto verification of insurance, precertification, and medical necessity," says Hovan. The technology will cost $120,000 per year, with an implementation cost of $80,000.

Process changes needed

Multiple payers have increased the required authorizations for radiology procedures, says Kathi Berzai, director of access services at Memorial Hospital of South Bend (IN).

"Our director of managed care services keeps us well informed of our payers and the new requirements," she says.

Radiology claims denials often result from add-on procedures ordered for the following day from the emergency department, says Berzai. In some cases, physician's offices state they have contacted the payer, which told them that no authorization was necessary. "Our current process is to contact the physician offices for the tests requiring preauthorization," says Berzai. "We relay to the offices that we are unable to give the necessary clinical information to secure preauthorization."

The department is searching for new technology to identify the radiology tests needing preauthorization and identify whether a preauthorization has been secured. "Currently, our registration staff is responsible for the follow up of preauthorization," says Berzai. "We are considering moving that process to our centralized scheduling department."

Obtaining radiology authorizations is difficult if outpatients have been sent directly from an urgent care center in the middle of the night or a weekend, or early in the morning after being discharged from the hospital's emergency department, says Doug Mast, support services manager of the Radiology Department at Moses Cone Health System in Greensboro, NC.

"Urgent care center staff are not used to obtaining prior authorizations," says Mast. "When they come from within our own ER, there isn't time to obtain the authorization prior to the study being completed."

Increase in two areas

Mast has seen an increase in the number of payers requiring prior authorization and the number of exams for which they are requiring prior authorization. 

"It's not just the private sector payers, either," he says. "North Carolina Medicaid requires prior authorization, and I do believe Medicare is heading in that direction as well."

The department has made process and procedure changes to address this issue, with schedulers now gathering insurance information at the time of scheduling. Staff members follow up with the ordering physician to ensure the authorization is received prior to the exam, and they will reschedule the patient if an authorization is not received prior to the exam, says Mast. 

"When a patient presents to be registered, and they present a different insurance card than what was previously used, that could impact the need for an authorization," notes Mast.

Sources

For more information on preventing claims denials for radiology procedures, contact:

• Kathi Berzai, Director of Access Services, Memorial Hospital of South Bend (IN). Phone: (574) 647-3366. E-mail: kberzai@memorialsb.org.

• Stephen R. Hovan, Executive Director, Patient Fiscal Services, The University of Tennessee Medical Center, Knoxville. Phone: (865) 251-4534. E-mail: shovan@utmck.edu.

• Doug Mast, Support Services Manager, Radiology Department, Moses Cone Health System, Greensboro, NC. Phone: (336) 832-8595. Fax: (336) 832-2210. E-mail: doug.mast@conehealth.com.

• Richard J. Suszek, Director, Patient Access, Barnes-Jewish Hospital, St. Louis, MO. Phone: (314) 362-5131. E-mail: rjs5021@bjc.org.