Radiology-Denials-blog

A Quick guide to Manage Radiology Denials

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Denials ManagementFree GuideNews

Keep an eye on Radiology Denials

Have you keenly observed the patient’s eligibility before submitting the claim for Radiology services? Better do that if you haven’t, as it would lead to a chance of encountering Radiology Denials.

Radiology is a specialty where the images of the body organs are elucidated to diagnose the disease. Radiologists refer to medical professionals who are specialized in interpreting medical images.

Radiologic technologists are imaging professionals who handle equipment for making images. Claims are often resubmitted after correcting the errors in patient eligibility details which could be the major cause for Radiology denials.

Medical Images of Radiology:

  1. Radiographs
  2. MRI
  3. Ultrasound
  4. Mammograms
  5. Fluoroscopy
  6. Nuclear Medicine
  7. Interventional Radiology
  8. Tele-radiology

Radiographs:

Radiographs are X-rays to image bones, chest and abdomen.

CT:

CT refers to “computed Tomography” In which X-rays of multiple angles from a machine form an image based on computer calculations.

MRI:

MRI stands for “Magnetic Resonance Imaging” where magnetic fields and radio waves are computer processed to make images.

Ultrasound:

Using sound waves to make moving images on a monitor with common examples of being fatal ultrasound during pregnancy and images of heart while performing echocardiogram.

Mammograms:

X-rays those are specialized powered and aimed for breast tissues.

Fluoroscopy:

Using X-rays those produce moving images of the body for procedures such as stents for blocked vessels as well as gastrointestinal tract.

Nuclear Medicine:

Short acting radioactive substances get into certain body parts to emit light from bodily processes those are collected by camera to form an image.

Interventional Radiology:

Image guidance is used for minimal invasive procedures for the treatment without open surgery.

Tele-radiology:

By transmitting radiology imaging to the remote locations or where the facilities are not found, the images are interpreted electronically.

How do Radiology services succour Healthcare? 

  • Radiology services can find out many challenges that help to improve the access to better healthcare with sophisticated technology.
  • It can aid to diagnose diseases like breast cancer and tuberculosis.
  • With the arrival of highly developed technologies, radiology images can be stored and transmitted electronically. Healthcare professionals analyze and detect epidemic quickly and accurately.
  • Radiology services can eliminate the need for exploratory services and can be used to determine the requirement for a surgery.
  • It acts as a visual guide for treating certain conditions of heart diseases and stroke.

Essential Guidelines for Radiology Billing:

  • Radiology medical billing involves utilization of significant CPT codes along with modifiers.
  • Many Radiologists have their own diagnostic priorities which may further result in payment delay or denials.
  • A written communication or format of Radiologists’ interpretation about Radiology study is called Radiology Report.
  • It’s crucial that the report should provide answers to all Clinical questions relevant to Radiology study.

Reasons for Radiology Denials:

  • A perfectly managed Radiology billing service submits the claims promptly and receive payments as quickly as possible.
  • Timely claim submission and quicker payments will enhance the revenue flow and reduce the cost of billing to the minimum.
  • When payments are often delayed, the insurance companies deny the claim based on their protocols.
  • Sometimes Radiology denials can be a burden for the patient with no good reason and their reaction is to call the provider’s billing office to raise a complaint.
  • It adds an extra work for healthcare to track the patient, research the problem, collect accurate information and resubmit the claim, which Timely Filing Rules the insurance company might impose.
  • The most common reasons for Radiology denials are:
  1. Patient Eligibility Errors
  2. Obtained improper authorization
  3. Failed to document the medical necessity for the examination.

Patient Eligibility Errors:

  • There are ways where claims are denied due to errors in Patient Eligibility.
  • It includes the details of incorrect site of services or inaccurate insurance company details or plan information on the claim and demographic problems that occur in the registration process.
  • Insurance companies especially Medicare, expect all necessary information of the patient that matches exactly with the records.
  • Any mismatched information will be the reason for the Radiology denials, bouncing back to the group to make required corrections.

Obtained Improper Authorization:

  • The prior authorization for imaging procedures with higher cost and arrival of ICD-10 diagnosis coding has increased the level of requirements in the authorization process.
  • Performing Radiology services without obtaining proper authorization will generate a Radiology denial. Also any mismatch or false details in the examination performed will be the cause for claim denials.
  • The insurance companies look for the information that matches the records and payment standards.
  • Unless everything lines up, Radiology services will be denied to receive any payments.

Failed to document Medical Necessity for an Example:

  • Insurance companies follow certain medical protocols that dictate the conditions under which the procedures have to be performed.
  • The healthcare provider should be sure that the exam performance is medically necessary in the diagnosis or treatment of patient’s condition.
  • It’s important to be cautious where only documented indication rules out a particular condition.
  • Usually, the denials for medical necessity results with the information conveys to the insurance but not from the patient care decisions.
  • So, good documentation is essential to support the exam including details of the patient history.

How to avoid Radiology denials:

  • A proper medical history from the patient will always provide the signs and symptoms that’s being presented.
  • The referring healthcare professional can also give the reason for the referral and that includes patient’s symptoms.
  • Some healthcare providers make an attempt to provide radiologists with signs and symptoms.
  • Technologist is a good source to gather good information at the time of exam.
  • Modality worksheets should be reviewed to be sure that they include questions about patient history, signs, symptoms and previous imaging.
  • Occupied with more information about the patient, its radiologists responsibility to include relevant information or the other details in the documentation of the procedure.
  • The coders and billers will claim preparation properly with the available details and audits the case.

How to Prevent Radiology Denials- Eligibility Problems

  • The submitted claims for payment clearance is often refused to pay by the insurance companies due to inaccurate information on patient eligibility.
  • The error in patient eligibility can be because of various reasons but not only under the control of radiology practice.
  • The claims can be recorrected and resubmitted to the following insurance payer under the timely filing limits.
  • The main way to avoid inaccurate details in patient’s eligibility is by improving the process of recording data at the time of patient’s registration.
  • Effective denial management can strengthen the bond between the healthcare professionals and the imaging center.

It’s evident that errors mostly occur when patients enter the information on their own which may not extract the actual response.

Radiology Denial Management:

  • The best course of action is to avoid the radiology denials by understanding the insurance company’s rules and gathering better information.
  • An appeal has to be filed after the provider feels that the claim denials are not accurate.
  • Here’s when the detailed information and documentation becomes invaluable, as it allows a case to be made for payments when the first claim form would have not contained necessary information.
  • A Radiology denial usually means that while insurance companies declines to pay, the patient still is capable to receive the payment.
  • However Medicare has specific rules that govern when the payments can be obtained from the patient.
  • Prior to the procedure that is either covered or non-covered by Medicare to be not medically necessary, patient must be given written notice using an Advance Beneficiary Notice form.
  • If failed to do so, the payment to be received or collected from the patient will be prevented.
  • When payers or insurance companies notify patient’s regarding payments after a denials, it’s not pleasing at all.

Action Plan for Radiology denials:

  • Understand the medical protocols and payment policies of various insurance companies.
  • Train the staff to gather detailed information of patient and insurance as much as possible.
  • Make sure the registration staff gather enough information and capable of questioning the patient when arrived for the exam.
  • Maintain updated technologist worksheet that includes absolute questions about history, signs and symptoms.
  • Understand which exam must be scrutinized and be sure to give accurate and complete information for these exams.
  • Internal review of cases those were denied has to be performed and feedback must be provided to the radiologists.
  • Monitor denial reports and act on trends those are identified. Gathering useful data about referring healthcare professionals, payer is essential.
  • Review denials and identify when an appeals appropriate.
  • Regular follow-up on the Radiology denials will keep the patient informed about the practice’s intentions.

AI in Radiology Denials:

  • Artificial intelligence and machine learning helps a lot in revenue cycle management process by improving radiology denial management and virtually removing troublesome errors that causes a claim to fail.
  • It’s improved automation process allows to capture data and have an interaction with various insurance companies to make the difficult tasks much easier.
  • AI can also involve in automate front end process that can submit clean claims and decrease denials with perfect denial management.
  • Radiology billing usually consumes a lot of time as well as resources to process a claim with follow up.
  • Automated processing can let prior authorization happen without any fault and remove negative effect on patient care.
  • AI also eliminates back end issues by using cloud based system to submit and update patient data directly and schedule the process efficiently and effectively.

Hope the above article gives you clarity on Radiology Denials. If you feel any key points untouched, feel free to comment. We will definitely consider adding them. To know the latest healthcare news, do subscribe our blog.

 

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