AHRA 2017: Medical necessity review can save imaging practices millions

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Pre-authorization can bog down the imaging process, but the University of Colorado Hospital in Aurora has taken ownership of front-end authorization and medical necessity review, saving time and money when compared to outside referral specialists.

This in-house review has reduced the time-to-authorization from five weeks to under 48 hours, according to Aaron Hackman, radiology reimbursement specialist at the University of Colorado Hospital.

“The whole premise of putting patients out and not scheduling them for weeks at a time until you get that authorization—we don’t do any of that,” said Hackman, who is giving a presentation on this topic at the Association for Medical Imaging Management (AHRA) 45th Annual Meeting and Exposition. “You only deal with a handful of patients who are problematic. Otherwise, you get them scheduled, scanned and done.”

The University of Colorado Hospital achieves this efficiency by moving the entire insurance authorization and verification structure under the umbrella of radiology, replete with experts on insurance requirements for imaging authorization. These referral specialists gather all pertinent clinical information, walking through the authorization with insurance representatives if they have any questions.

Selecting referral specialists with clinical experience is key—the questions insurance reps might have are in-depth, especially for imaging, said Hackman.

However, this workflow doesn’t just apply to plans requiring authorization for certain exams. Establishing medical necessity before an exam takes place can reduce unnecessary imaging and the financial burden on patients.

“A lot of plans don’t require authorization,” said Hackman. “Normally, when people hear that it’s usually, ‘Woo-hoo, scan ‘em!”

Quickly approving imaging exams can come back to bite patients, however.

“The exam still requires the same medical necessity fulfillment as it would an authorization,” said Hackman. “So as difficult it is to get an authorization with documentation on the front end, now you have to do it on the back end. There’s going to be some non-clinical billing people trying to sift through the documentation and shipping it off to the insurance company for review—those are frequently denied and the patient gets billed for that.”

Instead, exam orders are cross-checked with insurance guidelines and any discrepancies are dealt with in-house. A frequent flagged procedure is PET-CT for oncology imaging—common for surveillance if a patient has no new symptoms. Insurance guidelines tend to support simpler modalities like CT or MR, so it often falls on the insurance authorization team to reach out to the ordering physician.

“We say, ‘Do you have a reason why the PET-CT would be indicated over the CT?”

“They often come back and say, ‘Nope, CT scan’s fine.’ We downgrade from PET-CT and preform the approved CT scans which get authorized and paid for and everybody’s happy,” said Hackman.

Hackman believes University of Colorado Hospital is the only care provider in the country who establishes medical necessity on plans that don’t require pre-authorization, saying radiology managers often lack awareness about why claims get denied. This is costing other imaging practices in a big way: The hospital saves about $1.2 million a year by eliminating denials, according to Hackman.

“This stuff never has to go downstream to somebody else, which turns out to be an incredible amount of resources,” said Hackman. “Nurses, doctors, billing people who are mailing things back and forth—instead, we get it the first time and we’re way ahead.”