There are a wide variety of radiology procedures to help diagnose the cause of symptoms, monitor the body’s response to a treatment, and screen for different illnesses, such as 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 health plans require prior authorization or prior approval for imaging procedures and failure to obtain it will result in denial. 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.
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.
Many types of high-cost radiology procedures require prior authorization. These include CT (computerized axial tomography) scan, MRI (magnetic resonance imaging) scan, MRA (magnetic resonance angiography), PET (positron emission tomography), and nuclear medicine imaging (e.g., nuclear cardiac stress test), and CT colonography/virtual colonoscopy (for diagnostic purposes).
When the insurance company receives a prior authorization 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”.
Challenges Involved in Prior Authorization
While healthcare providers aim to provide the right services to patients as quickly as possible, payers require prior authorization to ensure that the procedures are appropriate, legitimate, and cost-conscious.
Obtaining prior approval quickly is crucial to provide timely care. However, obtaining prior authorizations is complicated and can delay critical care. In radiology, onerous prior authorization processes that delay approval for imaging tests for such as CT, ultrasound (US), MRI, PET, and single-photon emission computed tomography (SPECT) can significantly delay care for cancer patients.
Reports indicate that authorization-related issues are among the top reasons for claim denials. In a 2021 AMA prior authorization (PA) physician survey:
- 93% of respondents said that prior authorization can delay access to medically necessary care
- 34% of respondents said prior authorization A has led to a serious adverse event for a patient in their care/li>
There are many challenges involved with radiology prior authorization that make them difficult to manage for referring physicians and radiology practices:
- Different health plans have different rules with regards to prior authorization, and it’s important to be knowledgeable about them.
- Insurance companies often change their rules and procedures, so staying updated is crucial.
- If prior authorization 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
Radiology prior authorization requests are usually submitted and obtained by the referring physician, though some plans allow the radiology practice to do this. This also depends on state regulations.
The many challenges associated with radiology pre-authorizations warrant the need for expert assistance for managing the process. Fortunately, such support is available. Insurance verification and authorization service providers are 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 required 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 applicable medical codes
Denied requests would need time for resubmission and approval. With radiology insurance verification and 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.
Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.