Medical imaging is an essential element in modern medicine. Medical imaging technology continues to advance and radiologists have effective screening tools to detect potential health disorders or conditions, enabling patients to get proper and timely clinical care. However, one problem that continues to trouble radiology practitioners is claims denials due to patient eligibility errors. Using insurance eligibility verification services is the best way to overcome this problem.

Medicare and commercial insurance companies will reimburse radiology services only if claims contain accurate information about the patient’s eligibility for coverage.  The key to avoiding radiology claims denials is to obtain accurate information about the patient’s eligibility for the service before it is rendered. Health insurance eligibility verification at the time of patient registration should focus on obtaining information about the following:

  • Insurance plan information: This involves verifying the following for each patient:
    – Co-pays
    – Co-insurances
    – Claims mailing address
    – Deductibles
    – Patient policy status
    – Effective date
    – Payable benefits
    – Plan exclusions
    – Health insurance caps
    – Type of plan and coverage details
    – Referrals and pre-authorizations
    – Out of network benefits

It’s important to verify if the patient has secondary or supplemental coverage, which could be a vision plan, dental plan, or an accidental injury plan. Secondary health insurance can be also available directly to the patient or through a spouse’s medical plan. Primary and secondary plans work together to offer coordinated benefits to the member.

  • Demographic details: Getting the patient’s demographic information is essential for successful claims. Specific details that need to be collected are Patient name and ID#, gender, date of birth, Social Security Number, contact number, marital status, email address, residential address, and current employer. This information should be verified at the encounter.
  • Site of service: Radiology services are provided in different settings such as an imaging center, the outpatient department of a hospital, and physician’s offices. The level of co-insurance payment would be different for these facilities.  Site-of-service differences especially matter if the radiology practice has a capitated insurance contract, a health care plan that pays a flat fee for each patient it covers. This fee will be different for different sites of service. Proper coding is essential to prevent loss of reimbursement under capitated insurance contracts.
  • Prior authorization: Most insurance companies have specific prior authorization requirements for costly procedures including radiation oncology and high-tech imaging such as CT, CTA, MRI, MRA, MRS, Nuclear Cardiac, PET and CPT. Obtaining prior authorization 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.

Obtaining radiology prior authorizations start with verifying patient coverage.  The practice staff must also collect all information relating to the patient’s condition and the reasons for the exam. Imaging orders must be appropriate and complete. Once these details are obtained, the radiology department or imaging center staff can contact the referring physician’s office to see whether the referring office has obtained authorization from the insurance company.

Outsourcing the prior authorization process can save time and ensure an efficient, hassle-free process. A professional radiology authorization company would have a dedicated team that is knowledgeable about the following:

    – which plans require prior authorizations
    – Which procedures in each plan require authorization
    – Policy numbers that require specific types of authorization
    – How to obtain the authorization by calling the payer or contacting them through their website

Medicare and Medicaid have unique requirements for prior authorization. Medicare Advantage plans that commercial companies offer are different from standard Medicare coverage and have different submission requirements. Experts would be familiar with these rules and also up to date on payers’ changing rules and procedures related to prior authorization.

A radiologist-backed effort to rein in the onerous prior authorization requirements gained steam last year. Radiology Business reported that the aim of the bill is to increase oversight and transparency, reduce paperwork and delays, and streamline and standardize how Medicare Advantage plans use prior authorization. Among other proposals, plans would also be required to report their use of prior authorization and rate of denials.

As the insurance verification and pre-authorization process can be very time-consuming, and requires constant follow-up, radiology offices can benefit from partnering with an experienced radiology insurance verification company