Navigating the labyrinthine landscape of radiology billing can be challenging. Frequent updates to regulations and codes, pre-authorization requirements, varying insurance policies, accurate documentation, complex coding, and compliance needs contribute to the complexity of the billing process.
On top of that, claim denials can affect reimbursements and add to your administrative burden. This is where effective claim management can come to your rescue. It does not just revolve around resolving rejected claims but also finding the root cause, taking preventive actions and implementing strategies to reduce future occurrences.
A proactive denial management process not just helps you reimburse account receivables and reduce bad debt but also addresses loopholes in your billing process to improve cash flow in the long run. All these initiatives can help you focus better and completely on delivering excellent patient care.
Here are the 5 best practices for robust denial management in radiology medical billing.
Top 5 Strategies to Optimize Radiology Claims and Denial Management
-
Accurate Eligibility and Coverage Verification of Radiology Patients
Proper eligibility and benefit verification is needed to manage radiology denials and improve reimbursements. Insurance plans are modified every year, due to which benefits and coverage keep changing.
Imaging services, mainly advanced procedures such as CT scans and MRIs have unique coverage rules. If the patient’s insurance details are incorrect or outdated, it reflects as a billing mistake and the radiology claim would be rejected.
So, it is essential to verify patient’s insurance benefits and coverage to facilitate error-free radiology medical billing and coding and minimize the risk of eligibility-related rejections.
-
Establishing Medical Necessity of Radiology Treatments
Insurers require evidence of medical necessity of radiology services to approve claims. For instance, if a diagnostic imaging procedure is performed, the patient’s medical records should justify the need for this service. Therefore, it must align with the patient’s condition or symptoms.
While radiology centers may deem a procedure vital, the criteria to cover it can vary among insurers since their payment policies differ. Insurers may follow their own medical protocols that billers must consider before submitting claims to different payers.
That is why, for efficient denial management, radiology providers must provide clear and detailed documentation of the medical necessity of a procedure to justify its importance to the payer.
-
Obtaining Prior Authorization (PA) of Radiology Procedures
Complexity of radiology procedures has increased over the years. Advanced and expensive imaging procedures such as PET scans, ultrasonography, nuclear medicine, and MRI scans usually need pre-authorization for reimbursement. Failure to obtain it is a common reason for rejections.
A robust radiology prior authorization workflow is needed to lower these denials. For that, billers can take these steps:
- Document and submit the authorization accurately with the claim.
- Stay updated with authorization credentials of various payers to ensure a seamless radiology billing process.
- Keep in mind cases when PA is not needed. For instance, it is not required if the same procedures are carried out in other urgent care centers or ER.
-
Ensuring Correct Documentation of Radiology Services
Documentation errors are another reason for radiology billing mistakes. Inaccurate or incomplete documentation can cause misunderstandings about the rendered services. If payers do not get proof of what services have been provided, they cannot approve claims. As a result, those services would not be reimbursed.
To overcome this challenge, billers must take these steps towards radiology denial management:
- Communicate closely with patients to get correct information about the offered treatments.
- Perform thorough and accurate documentation of the radiology procedures for correct radiology billing and coding.
- Ensure all patient data including insurance and demographic details are up-to-date and accurate.
- Provide detailed descriptions of the performed procedures including any use of contrast materials, sequences, views and type of imaging.
- Use the correct modifiers to represent the nuances of a procedure accurately. These include modifiers for physician interpretations, incidental findings, and repeat studies.
- Document clinical indications in detail to prove a procedure’s medical necessity and justify the rendered service.
- Work with billers who stay updated on the latest documentation standard and coding guidelines.
- Ensure correct documentation and submission of prior authorization of radiology procedures.
- Use Electronic Health Record (EHR) systems to maintain detailed audit trails and document each change made to patient records. This gives a clear documentation history for audits and helps you comply with regulatory guidelines.
-
Avoiding Radiology Coding Errors
Accurate coding of services is crucial in radiology billing since imaging procedures use specialized codes, usually with detailed modifiers that should be applied correctly. A radiology report indicates a particular finding or a certain kind of imaging modality. Billers must use the correct corresponding codes to represent them.
Radiology coding errors can vary from minor typos to missing modifiers and wrong CPT codes. These can be avoided by working with trained billers who offer streamlined radiology billing services and stay updated on radiology-specific coding guidelines.
Outsource Radiology Denial Management for Seamless Operations
Addressing the above issues can considerably improve the denial management of your radiology center. However, handling so many billing intricacies can be overwhelming for your team and affect your time and other resources needed for patient care. So, let a trained team of denials and appeals management do the heavy lifting. They can identify any root cause of a rejected claim whether it is inaccurate eligibility verification, lack of prior authorization, coding errors or wrong charges and rectify any kind of billing error.
If you want to reduce your rejection rate and improve reimbursements, consider outsourcing radiology billing services to a trusted billing company like RCM Workshop. We house expert radiology billers experienced in revenue cycle management in your specific field. They remain updated on the unique challenges, opportunities, and trends in medical billing and use this knowledge to streamline your claim management process in the best possible ways. Act now to enhance the financial health of your practice!