Radiology Authorization Help Avoid Claim Denials

Hello and welcome to our podcast series. My name is Meghann Drella and I’m a Senior Solutions Manager here at Outsource Strategies International. Today, I’ll be discussing how obtaining radiology authorization can help avoid claim denials.

There are a wide variety of radiology procedures to diagnose symptoms of various conditions, 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 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.

00:54 Radiology Prior Authorization and Medical Necessity

The 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 scan, MRI scan, MRA, PET, nuclear medicine imaging and CT colonography/virtual colonoscopy. 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”.

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.

01:59 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.

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.

I hope this helps, but always remember that documentation as well as a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.

Thank you for joining me and stay tuned for my next podcast.