It took 10 years but diagnostic exam precertification, which requires referring physicians to obtain insurer approval for imaging services prior to scheduling scans, has developed into a reimbursement labyrinth. Now, insurers, radiologists, and referring physicians must all navigate the maze created by imaging's utilization (or overuse, as payors would put it).
"Precertification is not a new concept," said Christie James, radiology billing manager for the Massachusetts General Physicians Organization (MGPO), an affiliate of Massachusetts General Hospital (MGH) and Partners HealthCare System in Boston.
James' department manages the entire revenue and billing cycle for radiology professional services at MGH, including off-campus imaging centers. This adds up to an annual volume of more than 700,000 billed CPT codes, she said.
She shared how MGPO decided to handle the precertification situation during a presentation at the Radiology Business Management Association (RBMA) annual meeting earlier this year in Miami.
The shape of precertification
If the referring physician fails to obtain a precertification, or if insurers (or their agents) refuse precertification because of lack of medical necessity, the claim for the imaging service gets denied. Thus, referring physicians don't suffer the consequences if they fail to follow the appropriate precertification path.
Radiologists suffer in their stead, because insurers refuse to pay for the cost of exams without proper precertification in hand. And because insurers don't really want to wade into this warren of paperwork, they have now found a third party -- imaging management companies -- to further enhance the precertification maze.
In practice, precertification creates considerable chaos for radiology departments and facilities nationwide.
"It's a formidable management challenge," James said.
Although those managing radiology billing may wish to take a weed whacker to the precertification process, navigating payors' mazes can be accomplished.
Computer programs and other celestial intercessions
For James, divine intervention came in the guise of her information technology department, which put a little pixie dust into MGPO's computer programming and established several new imaging-order protocols to help her team receive proper reimbursement.
The radiology order entry (ROE) system is a Web-based program that includes a decision-support tree for referring physicians. Associated doctors access the portal via Partners HealthCare's intranet.
The ROE system brings the doctor to an exam-ordering page. From there, he or she chooses the imaging modality from a pull-down menu. A requisition form prompts the physician to provide information regarding clinical indications, signs and symptoms, and known diagnoses. The clinician must also include patient history and other pertinent information.
The application's decision-support framework provides physicians with immediate feedback based on Partners' appropriateness criteria. It then rates and color codes the order: green equals high use, or OK; whereas red warns the physician that they have requested a scan that's not typically used for the ailment described.
If the physician tries to go ahead with a red order, the program forces them to document the reason for requesting the potentially inappropriate exam. The program also provides a link to supporting documentation for each order's medical appropriateness.
"Perhaps the most important aspect of the ROE system is that it educates physicians on the precertification process and various requirements by payors," James said.
On its scheduling screen, ROE offers a precertification quick reference, making it easy for physicians to pick up the phone and get the approval number needed to complete the order form.
Mapping the maze
The No Administrative Hassle (NoAH) program attempts to electronically systematize the precertification process through an interface between Partners and certain contracted payers.
The NoAH screen requires the patient's name, date of birth, payor, and payor identification number. It also asks for the names of the referring physician and service provider (i.e., radiologist). The referral date, level of service, and type of testing requested must also be established.
Because it's all on one computerized form, the "system minimizes the precertification hassle for referring physicians," James said. "It eliminates the need for the referring physician to pick up the phone and obtain the precertification."
Although NoAH may add complexity to the process, it reduces the burden on the front-end radiology clerical staff, on the back end in reduced denials because of lack of precertification, and on the referring physicians, who don't want to spend additional time on payor paperwork.
Even after MGPO receives precertification through this process, payers still sometimes deny claims, James said.
Slay denials with precertification data
The battle for reimbursement won't be won by mere muscle. But let's say you've slain the precertification monster -- there's much more navigation to be done before you can escape the labyrinth unscathed.
Practical data analysis provides a trail for administrators to follow, James said. Create a database to capture information on procedures missing a precertification number. This enables rapid, root-cause analysis. Further, it facilitates a management response and also prevents future revenue loss.
Report all claims denied because of lack of precertification. Sort data by modality, CPT code, payer, and primary care provider, she said. Create regular retrospective reviews complete with cross-network charts. Have an internal panel of vested interests examine and debate the report.
Ensure that the radiology billing administration receives weekly and monthly denial reports, and that the reports contain pertinent information from all payors.
"Meet with everyone," James said.
Tools for the trail
As the radiology administrator, hold biweekly meetings with staff whom you've designated to keep tabs on the precertification process. Include coders as well as key members from the radiology finance, hospital, professional billing management, compliance, and accounts receivable teams.
"This provides for a greater understanding of factors associated with high-cost radiology utilization, and allows the whole team to discuss the direction of a radiology management program," James said.
For example, a breakdown of all precertification denials at MGPO showed lack of medical necessity as the top reason for rejection, she said.
"We use the information to see which docs are the worst offenders," she added. "Once we know that, we can focus on them, educate them, and show them how precertification works."
James counseled that the key to finding your way out of the precertification labyrinth is fairly simple: Stay on target and work as a team.
"As an industry, we weren't paying attention," she said. "Shame on us; precertification is here now and we have to handle it."
By Melissa Varnavas
AuntMinnie.com contributing writer
December 4, 2006
This article originally appeared in the "Radiology Administrator's Compliance & Reimbursement Insider," a monthly newsletter published by HC Pro that is designed specifically for radiology administrators. For a free trial subscription, please click here.
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Increase image reimbursement with a designated coder, August 7, 2006
Prevent IR coding whirlwind with basics, July 26, 2006
The added value of ACR accreditation, June 13, 2006
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