Radiology procedures play a crucial role in diagnosing the cause of symptoms, monitoring treatment effectiveness, and screening for conditions like cancer and heart disease. Interventional radiology modalities such as CT, ultrasound, MRI, and fluoroscopy are used to help guide procedures. The costs for certain medical imaging tests, treatments and procedures may vary among geographic regions. Many insurance companies require prior authorization (PA) or prior approval for imaging procedures. Prompt and efficient eligibility verification and radiology authorization is the key to avoiding the hassles associated with these time-consuming healthcare tasks and preventing claim denials.
Avoid delays and denials with precise and timely radiology prior authorizations.
Radiology Prior Authorization and Medical Necessity
The American Medical Association (AMA) defines prior authorization as a “health plan cost-control process that requires physicians and other health care professionals to obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage”. Health insurance plans require prior authorization for specific procedures, treatments and medications.
Most insurance companies have specific PA requirements for costly procedures including radiation oncology and high-tech imaging such as CT, CTA, MRI, MRA, MRS, Nuclear Cardiac, PET and CPT. They use the PA process to determine which procedures they believe are medically necessary before agreeing to cover them. Obtaining preapproval before providing these services is essential to prevent claim denials for them. There are state regulations on who can obtain pre-authorizations – the radiologist or the ordering physician.
When the insurance company receives a PA request for an imaging procedure, they will perform a review to determine its medical necessity. The request must be approved in writing by the payer in advance of the time of the service. Services are evaluated based on medical necessity, which means the “care is reasonable, necessary, and/or appropriate based on evidence-based clinical standards of care”.
Prior Authorization: Emerging Trends and Persistent Challenges
While healthcare providers aim to provide appropriate and timely patient care, they need to obtain PA by convincing payers that recommended procedures are appropriate, legitimate, and cost-conscious.
However, obtaining PA is complicated, often delaying critical care. In radiology, onerous PA processes delay approval for imaging tests such as CT, ultrasound (US), MRI, PET, and single-photon emission computed tomography (SPECT) can significantly delay care for cancer patients.
The process of obtaining PA places a huge administrative burden on doctors’ offices, often requiring them to complete substantial paperwork on behalf of patients for even the most routine procedures and medications. AMA survey data shows that practices complete 39 PA requests per physician a week, which is described as way too many. The 2024 American Medical Association (AMA) PA physician survey found that:
- Of the surveyed physicians, 93% reported that PA delays patient care, and 89% said it contributes to burnout.
- Patient care delays often result in treatment abandonment and poorer clinical outcomes—with 29% of physicians reporting serious adverse events.
- PA also increases healthcare costs and resource strain, as 80% of physicians report that patients frequently pay out of pocket for necessary medications.
Reports indicate that authorization-related issues are among the top reasons for claim denials. The AMA reported on a KFF analysis of Centers for Medicare & Medicaid Services (CMS) data which found that, in 2023:
- Medicare Advantage insurers saw more than 50 million prior authorization requests submitted on enrollees’ behalf.
- 99% of Medicare Advantage patients are enrolled in a plan with prior authorization on at least some services.
- Medicare Advantage insurers partially or fully denied 3.2 million of those requests.
- Among the denials, 11.7% were appealed.
- Among denials that were appealed, 81.7% saw the initial prior authorization denial fully or partially overturned.
There are many challenges that are specific to radiology prior authorization and imaging services coverage that make them difficult to manage for referring physicians and radiology practices:
- Different health plans have different rules with regards to PA, and it’s important to be knowledgeable about them.
- Insurance companies often change their rules and procedures, so staying updated is crucial.
- If PA is required for a procedure but not obtained, the claim can be rejected by the health plan even if the procedure is medically necessary and would otherwise have been covered. In this case, the patient may end up paying for it.
- Authorization denials increase A/R days, require time and work to appeal, correct or overturn, and lead to revenue loss.
Prevent Claim Denials – Outsource Radiology Authorizations
The PA process is costing physicians time and resources that could be better dedicated to patient care. Knowing why radiology claims get denied and how to prevent it is crucial for a smooth radiology billing workflow.
The many challenges associated with radiology pre-authorizations warrant the need for expert assistance for managing the process and claim denial prevention. Fortunately, such support is available. An insurance authorization company is well-equipped to help referring physicians submit and obtain prior authorizations for radiology procedures. Let’s take a look at how this works:
The first step is insurance verification, which involves obtaining and checking all the necessary information up-front. An insurance verification expert will verify the patient’s coverage to determine benefits as well as prior authorization requirements. If a prescribed radiology procedure requires pre-approval, the insurance verification specialists can help the provider complete this time-consuming process.
Mistakes made in the request form or not submitting the request in a timely manner are common reasons for denials. Outsourcing radiology verifications and radiology authorizations can help practices prevent denials and save time and money. Companies that provide these services have experts who have extensive experience in the field, including knowledge about insurance companies’ stipulations and rules. Dedicated support for prior authorization includes:
- Communicating with the insurance company and checking their website to check eligibility, benefits, and verify if a prior authorization is required
- Completing the prior authorization form in the required format and according to the latest guidelines
- Submitting the prior authorization request on time
- Requests are submitted along with documentation supporting the medical necessity of the specific procedure or test
- Use of the appropriate medical codes
Radiology Authorization Help Avoid Claim Denials
While insurance verification specialists can help navigate the PA process, physicians should ensure proper documentation for diagnostic imaging claims. According to Erin R. Stevens, CNMT, NCT, director of nuclear medicine at Oregon Heart Center, good documentation is the key to cardiac positron emission tomography PET prior authorizations (Cardiovascular Business).
She emphasizes that training physicians for what is needed in cardiac PET documentation will go a long way toward preventing payment and prior authorization bottlenecks. Physicians need to ensure correct medical necessity documentation and ensure that diagnoses is reported using the correct ICD-10 codes.
Denied requests would need time for resubmission and approval. With radiology insurance authorization services, providers manage these time-consuming administrative processes efficiently, and free up their staff for more important matters. Importantly, experts will ensure that the prior authorization procedure is completed within the stipulated time required to initiate the treatment plan, so that when approved, patients will not have to wait for the care they need.
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