Procedures That Require Radiology Authorizations

Hey all, this is Loralee Kapp, the Solutions Manager with Managed Outsourced Solutions. Today we are gonna talk about radiology authorizations and for a full list of codes associated with this podcast, please see the attached document.

Competent revenue cycle management (RCM) is essential for keeping medical practices and hospitals financially healthy. Obtaining prior authorization or approval from health plans to order specific medications, procedures or studies is one of the most challenging aspects of medical billing. The number of imaging studies requiring prior authorization has increased significantly in recent years, adding to the administrative burden. As managing radiology authorization in-house is time-consuming, stressful and costly, most providers rely on insurance authorization services.

00:47 Rising Importance of Radiology Procedures

As there has been a rise in the importance of the radiology procedures, the demand for imaging services has spiked tremendously over the last few decades. Medical imaging is used by a range of medical specialists, from oncologists to internists. It has become essential for almost all major medical conditions, and is the standard of medical care for diseases such as cancer, cardiovascular disease, trauma, neurological conditions, and many others. Advancements in technology have made imaging faster, more precise, and less invasive. This led to the wider use of imaging for more conditions and for more patients. In addition to its utilization for diagnostic purposes, imaging is also used to treat, manage, and predict illnesses.

The increase in the type and volume of imaging procedures has increased the complexity of radiology workflow. Prior authorization requirements add to the challenge.

01:46 Prior Authorization Challenges

So, what are some other changes in prior authorization?

Many plans utilize prior authorization to determine the appropriateness of medical imaging studies before the procedure is performed by the imaging provider. The primary goal of prior authorizations in radiology is to control over-utilization and inappropriate use of high-cost imaging services.

However, MGMA notes that prior authorizations obstruct the delivery of timely patient care and medical groups are continuing to face the unprecedented challenges stemming from the COVID-19 pandemic. Along with the sharp rise in prior authorization demands, practices reported increased denials, delayed approvals for care, and constantly changing rules. If an authorization is denied, the provider has to appeal or wait 45 days to resubmit the request, further affecting delivery of care.

02:39 Prior Authorization Process

The prior authorization process starts when a specific imaging procedure is recommended for the patient that requires obtaining advance approval from the patient’s health plan to qualify for payment.

The imaging center has to submit prior authorization requests using the appropriate codes. Requirements differ among plans, even those from the same insurance company.

03:03 Reasons for Prior Authorization Denials

Prior authorizations are challenging as insurance companies can deny a claim for a radiology services for various reasons:

• Not meeting payer guidelines
• Failure to obtain prior authorization before the exam was performed
• Incorrect or incomplete information about the exam
• Outdated insurance information such as the policy has expired
• Procedure is not medically necessary
• Procedure is experimental or
• Incorrect codes, and other errors

In addition to the CPT-HCPCS code, prior authorization requests have to include the specific ICD-10 codes.

03:41 Why Outsource Prior Authorization?

Due to the complexity of the process and the frequently changing rules and procedures of insurance companies, it can be difficult for imaging center staff to manage. Outsourcing the task to a medical billing company that provides comprehensive insurance verification and authorization support is the best solution. These companies have insurance authorization and verification specialists who are well-versed of which plans require prior authorizations, and which radiology procedures within each plan require authorization, and how to obtain the authorization. In addition to obtaining and verifying the patient eligibility prior to the provision of service, they will ensure that the prior authorization request is submitted with the appropriate codes, documentation, and according to the plan’s guidelines, which working with an expert can help imaging centers increase revenue, improve provider and patient satisfaction, and prevent delays in patient’s care.

We here at Managed Outsourced Solutions are happy to help with any of your back office needs such as billing, authorization or verification services. So, please feel free to reach out to us at any time.