EXECUTIVE SUMMARY

Payers increasingly are denying claims for “stat” imaging because of no authorization. The following practices can help avoid problems:

  • Alert the verification team of a patient’s need for stat imaging.
  • Contact physicians’ offices to get the required clinical documentation.
  • Ask radiology technicians to identify if incorrect tests were ordered.

A sudden uptick in denied claims for “stat” imaging led to some important changes for the patient access department at Palos Health in Palos Heights, IL. In almost all cases, payment was denied because of failure to obtain authorization.

Previously, payers reimbursed for any stat order without problems. That has changed. “Recently, we’ve seen an increase in denials — no matter what the business office was doing on the back end to try to secure payment,” reports Dan Landsman, patient access manager.

Earlier Notification

As of October 2016, patient access took on the role of obtaining authorizations for imaging services. The department devised a simple but effective solution to combat the surge in denials by creating an email distribution list.

The group of 15 recipients includes the vice presidents of finance and support services, radiology leadership, scheduling verifiers, and patient access leadership. Whoever schedules a stat imaging test emails the entire group with the patient’s name and medical record number, the type of imaging and location, and the name of the ordering physician.

“It’s really increased communication between the front end and the authorization piece,” says Landsman. “This is something that really wasn’t being handled before.”

Once the verification team receives the email, they inform the payer right away of the patient’s need for stat imaging. “We believe it will lead to a reduction in denials,” says Landsman. “It will also allow the billing office to do what they do best.”

Prompt notification makes it difficult for payers to argue that patient access failed to contact them in the required timeframe. “There’s a discussion within that initial time frame, instead of a claim going out three or four days later with no communication,” says Landsman. The same process is used at the health system’s newly opened, freestanding imaging center.

Previously, the back end appealed the denied claims, but with little success. Even if a claim ultimately was paid, it was a very time-consuming process. “The lifespan of getting a denial overturned can be months,” explains Landsman. “The ultimate goal is that a clean claim goes out the first time and gets paid.”

Clinical Need Challenges

About 10 to 15 stat imaging tests are scheduled each day. The number is expected to increase with the opening of the new imaging center, since most of the health system’s physician practices are located in the same medical building.

Patient access director Katie Freese, MBA, explains, “We never had a process for this before. We made an assumption that because it was an emergent need, an authorization wasn’t needed.”

Even with stat requests, payers sometimes want proof that the test was really medically necessary. If the physician is within the health system, this is an easy task. Patient access simply pulls documentation from the electronic medical record. However, if it’s a patient from outside, the team has to contact the physician’s office. Some are very accommodating; others are less so. “That can be challenging,” says Landsman. “But the verification team does everything it possibly can to obtain that information.”

A similar process is used for add-on patients. These patients are treated the same as stat patients, unless verifiers get a sudden surge in volume. “We can’t always treat an add-on like a stat,” says Freese. “That is probably the ultimate in customer service. But the reality is, our resources are limited.”

If an add-on can’t be scheduled immediately, registrars use this scripting: “We would love to schedule your CT scan. We’ll go in this private room and get a scheduler on the phone.”

Turnaround time for imaging usually is very quick, however, keeping satisfaction scores high. Landsman credits this to good communication: “There have been plenty of times when, in talking with scheduling, we find ways to get patients the service they need.”

Changes “on the Fly”

Another frequent cause of imaging denials is that something changes during the actual procedure. “There’s a lot of things that happen on the fly when the patient is on the exam table,” says Landsman. It may be that a CT with contrast is needed, but the only authorization in place was for a CT without contrast.

Doing the second test on the spot can save the patient from scheduling a follow-up appointment and avoiding needless radiation exposure. To head off problems, patient access asked radiology technicians to look at schedules days in advance. “If they see something that should be changed, they alert us,” says Landsman. Two common examples:

  • An order is for CT with and without contrast, but only a CT with contrast is clinically indicated;
  • The order is for CT of the abdomen or pelvis, but payers are likely to want the target organ(s) identified.

Technicians alert patient access of any discrepancies. “We then reach out to the provider and get updated orders,” says Landsman. “If a different authorization is required, we are able to get that.”

SOURCES

  • Katie Freese, MBA, Director, Patient Access, Palos Health, Palos Heights, IL. Phone: (708) 923-4128. Email: kfreese@paloshealth.com.
  • Dan Landsman, Manager, Patient Access, Palos Health, Palos Heights, IL. Phone: (708) 923-5863. Email: dlandsman@paloshealth.com.