Department gets ahead of 'mismatch' denials

Annual radiology total is $2.5 million

Almost all private plans now require authorizations for radiology services, reports Richard J. Suszek, director of patient access at Barnes-Jewish Hospital in St. Louis, MO, and Missouri Medicaid began requiring authorizations in July 2010.

"The only payer not requiring authorizations is traditional Medicare, and that may change as well," says Suszek.

The most common reason for radiology denials is the "mismatch," when one particular scan was authorized but a completely different scan was performed, says Suszek. "The amount of radiology denials for mismatches is about $2.5 million on an annual basis," he says. "Typically, without contrast material was authorized, and with contrast material was performed."

Getting the correct CPT-4 codes to match throughout the process is key in reducing the risk of denials in this area, he says.

The department is making significant work flow changes and investments in personnel and technology to avoid these denials, reports Suszek. "We plan on creating a separate department, first within radiology, to make sure we get ahead of the issue," he says. "We will hire about four FTEs just for radiology, as well as spend another $250,000 in purchased services for technology support from an outside vendor."

Here are three changes being made:

• Starting with scheduling, registrars will ensure that a correct pre-certification has been obtained prior to the patient's arrival.

• Late add-ons and walk-ins will go through a similar, but more expedited, process.

• In some cases, a patient's procedure will be delayed or rescheduled if an authorization has not yet been obtained.

Hold technicians accountable

The number one reason why claims are denied for radiology procedures at Moses Cone Health System in Greensboro, NC, is that the examination performed doesn't match what was authorized, according to Doug Mast, support services manager of the radiology department.

"We had a real learning curve with our physician community, in getting them to order the correct exam to begin with," says Mast. "In our facility alone, there are over 2,000 different exams that can be performed."

Exams might be ordered incorrectly by the ordering physician or the radiology scheduler. "With such a large volume of exams, it's tough to know the ins and outs of every exam," says Mast. "An exam may be changed by the tech when the patient is on the table."

A technologist might change an exam based on the history received from the patient or based on findings during the originally scheduled exam. For example, a CT of the abdomen might be ordered, but the patient says the pain has moved to the pelvic area, or a CT of the abdomen doesn't highlight an entire organ because of the patient's anatomy, so a CT of the pelvis is added.

Similarly, a cardiac CT scan might be ordered instead of magnetic resonance imaging or a CT scan instead of an ultrasound for better image quality. "Technology is always changing," says Mast. "It is almost impossible for a primary care physician to keep up with the changing exams and exam protocols."

Regardless of the reason, the technician needs to notify prior authorization staff of the change and be more aware of the business side of healthcare, says Mast. To address this issue, access staff have educated technologists about the need for prior authorizations. "We had buy-in from radiology leadership to hold folks accountable," says Mast. "We consistently followed up with personnel when there were mistakes. We showed the tech the error and also included the dollar amount we lost as a facility."