The referring physician/radiologist relationship can be strained. As doctors themselves, radiologists are not always sure how much information and interpretation the referring doctor wants. Some physicians want only the minimum. They feel that because they have more patient details, they should direct care. On the other hand, other doctors want abundant communication in reports, including details on diagnosis, insights, and recommended treatment.
This conflict is complicated further when doctors send imaging requests to radiologists that go beyond the limits of the established prior authorization.
For instance, the prior authorization in the radiologist’s hands stipulates MRI without contrast, but the provider has written that an MRI with contrast is now necessary. With the patient standing in front of them and/or with pressure from the provider, the radiologist now must navigate how to get the patient the needed tests, whether to proceed or send the patient home. These situations can pose administrative and even moral dilemmas.
Review here what you can do when faced with requests that diverge from the prior authorization so you can be prepared.
Know payer guidelines in depth
In cases of these last-minute changes, it’s helpful when the radiologist has a clear understanding of each payer’s prior authorization guidelines. When an imaging center deals with dozens of payers, however, keeping individual guidelines straight can be a challenge.
Some payers have you submit your claim and then appeal for medical necessity. Other payers allow you to do a retroactive prior authorization.
With a retroactive prior authorization, it’s important to include the circumstances surrounding why the change or addition didn’t appear in the initial authorization.
Remember, too, that payers stipulate specific timeframes and guidelines pertaining to retroactive prior authorization. Some payers allow providers two days to file. Others allow a maximum of 45 days. Of course, you must take these steps before you submit the claim.
Documenting and tracking changes in PM and EHR
Once you make a real-time change, make sure to enter it in the patient’s chart in your practice management or electronic health records system. Most often it’s a simple matter of having the prior authorization specialist add a task to the patient’s account for prior authorization. Be sure to include time, date, and follow-up note. For example: “Smith, Jane—Task: Prior Authorization sent 11/16/2021 to BCBS via portal.” Setting a reminder to follow up on the task within 24 hours helps ensure the prior auth proceeds smoothly. The patient authorization will get a pop-up reminder when the biller opens the practice management system.
But payers need more than a few notes when treatments beyond their prior authorizations occur. In the case of a change, payers insist the provider include documentation that justifies it. Radiologists can check that this additional documentation supports the change and that it provides detail on why new procedures are medically necessary. Contact the referring provider and remind them of the need for thorough documentation. Let the provider know that, in addition to information on diagnosis and requested tests, payers will be looking for notes on the patient’s progress, response to treatments, and changes in diagnosis or treatment. Payers also want providers to include any patient non-compliance should be included in the medical record.
Radiologists can act as a reviewer for the provider. A quick call to the provider’s office gets the claim buttoned up. While radiology doesn’t get paid for this extra step, it can help ensure the lab gets appropriate compensation for all imaging.
Specific payer guidelines are just a few clicks away
Even though radiology groups don’t initiate prior authorizations, they often find themselves wading through payer guidelines and bureaucracy in order to get their claims paid. You can read more about cutting costs and improving radiology reimbursement in our recent post.
When imaging centers turn what can be a two- to three-hour scavenger hunt over to AI-driven automation, they save themselves delays and hassle. A prior authorization system that is entirely up-to-date and current on payer guidelines takes just minutes to render answers about prior authorizations and retroactive prior auths in minutes. Radiology gets same-day appointments approved within four hours and emergency or STAT requests approved in as little as 20 minutes.
Let us show you the best ways to access payer guidelines – request a demo today.
