The goal of a well-managed radiology billing operation is to submit claims for services promptly and receive reimbursement as quickly as possible. Timely submission and prompt payment enhance the practice’s cash flow and keep the overall cost of billing at a minimum.  All too often, however, payment is delayed because the payer denies the claim for some reason. 

Claims denials sometimes put the entire burden of payment back on the patient’s shoulders, usually without good reason, and their immediate reaction is to call the practice’s billing office to complain. This creates additional work for the billing office to handle the phone call, research the problem, obtain corrected information, and re-submit the claim – all of which must be done before the expiration of any timely filing rules the payer might impose. 

In my experience managing the revenue cycle for several radiology practices, three of the most common reasons for claims to be denied are:

• Patient eligibility problems,
• Failure to obtain proper authorization for the procedure, and
• Failure to document the medical necessity for the exam.

There are quite a few ways claims can be denied due to problems with patient eligibility. These include listing the incorrect site of service or the incorrect insurance company (or plan) information on the claim, as well as demographic issues that occur in the registration process.  Insurance companies, particularly Medicare, expect all of the pertinent information about the patient to correspond exactly with their records.  Any mismatch along the way will create a denial of the claim, bouncing it back to the radiology group to make the correction.

Many insurance plans require prior authorization for imaging procedures, especially those that are higher in cost, and the advent of ICD-10 diagnosis coding has increased the level of specificity required in the pre-authorization process. Performing these services without first obtaining prior authorization will generate a denial.  A mismatch between the exam performed and the authorization will also cause a denial.  Again, the payer is looking for information that matches its records and payment criteria.  The radiology group will not be paid until everything lines up.

Payers have medical protocols that dictate the conditions under which certain procedures are to be performed. The physician must be sure that the performance of any exam 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. Denials of claims for medical necessity usually result not from the physician’s patient care decisions but rather with the information conveyed to the insurance payer.  Good documentation to support the reason for the exam is crucial, including details from the patient’s history.

A good medical billing service will proactively manage claims denials, hopefully in advance of the patient’s phone call. But even so, a far better solution all around is to avoid denials in the first place.  The process of successfully generating clean claims that are paid the first time they are submitted begins with gathering accurate data even before the patient exam takes place, then ensuring that the claims are complete and accurate.

This is hardly a new topic, but it is one that needs constant attention in order to maintain efficient billing and optimize cash flow for a radiology practice. Our article from September 2013 contains valuable information about how to handle denials that are received.  Over the next few months we’ll cover these reasons for radiology claims denials in more detail and show you how to avoid them.  Subscribe to our blog to receive these articles as soon as they are published. 

Sandy Coffta is Vice President of Client Services at Healthcare Administrative Partners

Related articles:
How to Avoid Radiology Claims Denials – Eligibility Problems
How to Avoid Radiology Claims Denials - Authorization