When the radiology physician submits the error-free claim on time then the practice’s cash flow will improve and the overall operational cost gets minimized. However, you may find delays in payment due to radiology claim denials from the payer for some reasons.
When claims get denied, the patient will be vulnerable first as the entire burden of paying back falls on the patient’s shoulders. In such situations patients tends to call the practice’s billing office to complain then the billing office need to handle the phone call, research the problem, obtain corrected information, and re-submit the claim within the stipulated time.
Now, let us discuss how you can manage radiology claim denials:
Patient eligibility problems
Are you deeply observing the patient’s eligibility before submitting the claim for Radiology services? Because the problems with patient eligibility can lead to a chance of encountering radiology claim denials. The problems with the patient’s eligibility include the incorrect insurance company (or plan) information on the claim or listing the incorrect site of service.
Various payers especially Medicare, expect all related information about the patient to correspond exactly with their records and a mismatch with the information will create a denial of the claim. This denied claim needs to rework by the radiology group to make the correction which adds extra effort.
Apart from eligibility problems, providers should look for Prior authorization some services need PA for payments. Let’s discuss the assessment of PA requirements in detail.
Assess pre-authorization requirements
The radiologist should obtain prior authorization before rendering the services as payments are denied for procedures performed without the required authorization.
Radiology exams that may require pre-authorization include:
- Bone Mineral Density exams ordered more frequently than every 23 months
- CT scans (all diagnostic examinations)
- MRI/MRA (all examinations)
- Nuclear cardiology
- PET scans
- Stress echocardiograms
This PA should begin at the time of the patient’s registration for an appointment. In this process, the front office staff must gather as much information as possible about the patient’s condition and the reasons for the exam.
The payer is looking for information that matches its records and payment criteria hence all details are important and sometimes radiology department or imaging center staff need to contact the referring physician’s office. Once everything gets lined up then only the radiology group will be paid.
Failure to document the medical necessity for the exam
Under this category, the claim denials usually occur due to the information conveyed to the insurance payer and not from the physician’s patient care decisions but when it comes to supporting the reason for the exam is crucial good documentation helps, including details from the patient’s history.
For Example – There are certain protocols from payers for the condition under which certain procedures are to be performed. The healthcare provider should be sure that the exam performance is medically necessary in the diagnosis or treatment of the patient’s condition being cautious not to order tests where the only documented indication is to ‘rule out a particular condition.
Use of technology for radiology claim denials
The use of technology plays a big role in the revenue cycle management process like Artificial intelligence and machine learning helps in improving radiology denial management and virtually removing troublesome errors that cause a claim to fail.
These technologies also enhanced the automation that allows to capture data and have an interaction with various insurance companies to make the difficult tasks much easier and lastly, AI can submit clean claims and decrease denials with perfect denial management by automating the front-end process.
Now you can easily manage radiology claim denials, still, you can outsource your radiology billing to a leading medical billing company like us. We are one of the best radiology billing company and we help you to minimize the denial rate and maximize the billing collections.