HAP Radiology Billing and Coding Blog

How to Avoid Radiology Claims Denials – Eligibility Problems

Posted: By Sandy Coffta on June 18, 2016

425x240_eligibilty_probs_blog.jpgClaims for reimbursement of radiology services are most often denied by the payer, whether it is Medicare or a commercial insurance company, because they contain inaccurate information about the patient’s eligibility for coverage. This can occur for many reasons, some of which may not be within the control of the radiology practice, but it usually can be corrected by improving the process of recording data at the time of patient registration. In this new healthcare economy where radiology practices are under pressure to add value to the patient care delivery system, effective management of claims denials can strengthen the relationship between the practice or imaging center and the hospitals they serve.

Focus on Insurance Plan Information First

Obtaining the correct insurance plan information is vital to proper payment. The name of the specific plan, the subscriber number, the group number and the coverage effective dates, are critical.  Information about any secondary or supplemental coverage, whether it is obtained directly by the patient or through a spouse’s coverage, is also important for full reimbursement. 


Governmental plans such as Medicare and Medicaid present unique challenges. Medicare Advantage plans offered through insurance companies are not the same as regular, traditional Medicare coverage and they must be submitted differently.  We have found that errors often occur when patients are entering their own information through systems such as registration kiosks; these systems might not elicit the appropriate response from patients who think their coverage is through Medicare when it really is through an insurer’s Advantage plan.


Patients with Medicaid tend to change their coverage quite often, so it is imperative that the registration protocol includes examining ID cards and verifying coverage in advance of providing services. Be especially aware of effective dates with Medicaid coverage, as they often can become effective retroactively.  In some areas, Medicaid programs require patients to select a Medicaid managed care plan.  If the patient has such a plan, claims submitted directly to Medicaid will be denied.

Site and Type of Service

It is important to distinguish between a physician office setting, such as an imaging center, and the outpatient department of a hospital when submitting claims. Many insurance plans pay for services in each of these facilities differently and in some cases there could be no coverage at all for certain services in a particular location.  In recent years hospitals have been acquiring physician offices and operating them as an extension of the hospital outpatient department, which usually yields higher reimbursement, but to the patient they appear to be a physician office or imaging center.  Registrars should make sure patients understand this difference so they are prepared for the appropriate level of co-insurance payment.


Radiology practices with capitated insurance contracts have to be especially careful about site-of-service distinctions. Each capitated contract is unique, so the practice has to understand the terms of its own agreements and apply them properly.  For example, certain services at the hospital might be paid separately as fee-for-service, whereas office services might be included in the monthly capitation payment.  Other office services might be ‘carved out’ of the monthly capitation allowance.  Improper coding could lead to the loss of reimbursement under the contract.


One of the most obvious, yet often overlooked, elements necessary to submit clean insurance claims the first time is to review and verify the patient’s basic demographic information. This should be done at each encounter with the patient, and should include address, phone number, date of birth, email address, and current employer.  The latter is important because if the patient answers that he or she has a different employer, it is likely that their insurance information has changed as well.  Verifying the patient through inspection of a photo ID card is a good way to prevent problems due to insurance theft, which is a growing concern for all healthcare practices.

Leveraging Technology and Sharing Information

Radiology practices often must rely on the hospital’s registration department for their billing data. If the practice has its own imaging center system then it can be cross-referenced to help identify any differences of information for mutual patients.  The practice (or its billing service) should be able to run a report of eligibility-related denials by location to highlight where issues are occurring.  The discrepancies between the two systems can then be investigated. 


Both hospitals and imaging centers can use an eligibility verification system to confirm that insurance information is valid. Insurance eligibility reports are available and these can be compared with patient registration reports to assure that the patient insurance coverage information is correct.  Sharing this information with the hospital will help them avoid eligibility denials, improve the data coming to the radiology group, and it will also strengthen the radiology group’s relationship with the hospital. 

Action Plan

Avoiding the denial of payment due to eligibility errors is a relatively simple task.

  • Implement a protocol to review current information for accuracy, and obtain corrected information when necessary.
  • Train your registration staff on the key elements to be aware of, especially those that can trigger denial of a claim for radiology services.
  • Develop a partnership with your hospital that fosters a bi-directional sharing of information that will benefit both parties.
  • Implement automated systems that leverage technology to coordinate information across these systems when possible.

More on Managing Insurance Claim Denials

A problem with patient eligibility is one of the three biggest reasons for radiology insurance claims denials, along with lack of proper authorization and inadequate documentation. We will explore these latter two topics in detail in upcoming articles, so be sure to subscribe to our blog to receive them as soon as they are published.


Related articles:

The Top 3 Reasons for Radiology Claims Denials and How to Avoid Them
How to Avoid Radiology Claims Denials - Authorization

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Topics: radiology reimbursement, denial management, claims denials

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